Kensington Midwives - Intake Form

To request care with one of our midwives please fill out the intake form below to the best of your ability. If you have any questions or are having difficulty with this form please call our office at 416-928-9777 to complete the questionnaire over the phone. Once we receive your information we will contact you at the email address provided within 2-3 business days to let you know if there is a team available for you.

Do you have a health card? (ie. OHIP, IFH, UHIP etc.) * *
Name *
Name
Your Birth Date
Your Birth Date
Your Address
Your Address
Your Best Contact Number
Your Best Contact Number
Can we leave a confidential message at this number?
Name of your partner/support person
Name of your partner/support person
Your partner/support person's contact number
Your partner/support person's contact number
Are you planning to move during your pregnancy?
First Day of Last Menstrual Period
First Day of Last Menstrual Period
Are you certain of the date of your last menstrual period?
Do you have a 28 day cycle? (every 28 days)
If known, please enter your estimated due date
If known, please enter your estimated due date
Where would you like to give birth?
Have you had any previous births?
How did you hear about Kensington Midwives?
We strive to provide culturally sensitive care for all clients. Currently, we have midwives who can provide care in Spanish, Portuguese and French. Please indicate if you would like to request one of these midwives to be a part of your care team (if available).
Please check all that apply
We strive to provide inclusive care for people of all sexualities and family structures, across the gender spectrum. Please indicate if you would like to request a midwife with expertise in working with LGBTQ* clients.
(if available)