Register For Midwifery Care at KCM
First Name
Last Name
Your birthday (date of birth)
Email
Phone Number
Address
If you are partnered, what is your partner's first and last name?
Select the first day of your last menstrual period (If you do not know, use your best guess or leave blank)
If you have had a dating ultrasound and have been given a due date, please enter it here. If not, you can skip this question.
Number of previous pregnancies
Number of children
Did you have any complications in your previous pregnancy(ies)? (e.g. high blood pressure, cholestasis, gestational diabetes, etc.)
IF you have had a cesarean section delivery, are you planning a VBAC (vaginal birth after cesarean section)?
Select an option
Planning VBAC (I have had one cesarean section)
Planning VBAC (2 or more cesarean sections)
I am not sure yet, and would like to know my options
Repeat elective cesarean section
Have you had midwifery care in a previous pregnancy?
Select an option
Yes, I am a repeat client at Kawartha Community Midwives
No, I have never had midwifery care
Yes, but at a different midwifery clinic
Do you know where you would like to have this baby? (Note: you do not have to make this decision right now)
At home
KCM clinic birthing suite
PRHC (Hospital)
I am undecided
Please detail any significant health conditions that you have that you think we should be aware of (e.g. cardiac, PCOS, thyroid, high blood pressure, diabetes, auto-immune, injuries or impairment)
Please list any prescription medications you are currently taking.
Name of your family doctor (GP) or Nurse Practitioner (NP). If you do not have a primary healthcare provider, leave blank.
Have you had any bloodwork or ultrasounds done in this pregnancy yet?
Yes, I have had some bloodwork done
Yes, I have a had an ultrasound
No, I have not yet had any care in this pregnancy
Midwifery care is free for all Ontario residents whether they have OHIP or not. Select the option that best describes your situation.
Select an option
I am an Ontario resident with OHIP coverage
I am a newcomer to Canada and am still waiting for my OHIP coverage to start
I am an international student with UHIP coverage
I am a visitor to Canada and have private health insurance
I am a student from another province and have health insurance in my home province
I don't have any health insurance coverage
Any additional information that you think we should know (e.g. your preferred pronouns)
How did you hear about us?
Internet/Google search
Social media post (i.e. Instagram)
Friend or relative
My doctor or Nurse Practitioner
Other
Repeat KCM client
By checking this box I am agreeing to your receiving this information and using it only to facilitate my registration for care at KCM.
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