Become a Client - Guelph Midwives

Were midwives from this practice in attendance at any prior births?

Yes
No

What month and year was that?

Are you hoping for a specific midwife or team for this birth?

Yes
No

If so, which midwife or team?

First Last

Name of Family Doctor:

First Last

Address of Family Doctor:

Street Address City Province Postal Code

Phone number of Family Doctor:

Have you seen any other care provider for this pregnancy? (Family Dr, OB or another Midwifery Practice)

Do you plan to have your baby at

Guelph General Hospital
Groves Memorial Hospital
Considering a home birth
Not certain at this time

Is there anything else you would like us to know?

To request midwifery care, you can call our office or fill out this form online.

We will do our best to accommodate your request, but if we are unable to take you into care at this time, we will add your name to our waiting list. By filling out this form you are asking for care from a midwife and agreeing to allow us to collect this information. Within approximately 2 business days we will let you know if we have availability to take you into our care. Any information you provide will be stored in accordance with our privacy policy. Whether your request is accommodated or not, we send the following information; name, date of birth, postal code and expected due date; to the ministry to inform them of local demand; by submitting this form you are providing consent.

Please be aware that we cannot guarantee the security of your private information while it is in transit by email. If you have any concerns about sending personal information via email, please feel free to call our office (519-823-9785) and speak to us directly.

You will receive an automated acknowledgement of this request but please also watch your inbox (or spam folder) for an email reply within the next few days.

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Request For Midwifery Care

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