Intake Form

Name *

First Name

Last Name

Your Date of Birth *

MM

DD

YYYY

Address *

Please provide a unit number if you live in an apartment or condo

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

We require a Canadian phone number in order to reach you.

(###)

###

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My estimated due date is: *

Please provide your estimated due date (given to you if you've had an ultrasound) or calculate it by selecting "First day of your last menstrual period" and inputting your information using this calculator: https://perinatology.com/calculators/Due-Date.htm

MM

DD

YYYY

Who has provided care to you in this pregnancy? *

I have not yet received any care

Family Doctor

Obstetrician

Midwife

Nurse Practitioner

Walk-in Clinic

Where are you planning to give birth? *

You can select more than one answer if you are unsure:

Ottawa Birth and Wellness Centre

Hospital (TOH-Civic Campus only)

Home

Not sure

Do you identify as a member of any of the following groups?

You can select more than one

Racialized

LGBTQ+, or gender non-conforming

Experiencing a form of social insecurity such as: Person experiencing homelessness or inadequate housing, food insecurity, low income, single parent, teenaged parent

Refugee or recent immigrant to Canada

Person living with a disability

Trauma survivor

Other

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