New Client

If you are pregnant and interested in care, please fill out this form and one of our administrators will be in contact with you shortly.

All information provided will be held in confidence.

If you have not heard back from us in 2-3 business days, please call the clinic to follow up at 613-253-3148

Contact

First day of your last period
When is your Expected Due date
Your full name
Your partner's name
Phone numbers to reach you
Email
Your full address
Is this your first pregnancy?
How Many babies have you had
Have you had a previous C-section
Your date of birth
What is your height?
What is your weight?
Choice of Birthplace
Do you have any health concerns or medications you are taking?

Tell us about your Previous Delivery/deliveries

Where did you hear about us?

*To help the Ministry of health get the information it needs, we have agreed to ask individuals we are unable to accommodate at our Practice Group whether they would be willing to provide some basic personal information on consent - specifically initials, birth date and postal code - which we would provide to the Ministry. The Ministry needs this basic information in order to properly conduct a study to assess the demand for midwidery services in the province and will use it for no other purpose