Request A Midwife

Client Intake Form

Thank you for your interest in midwifery care. Please complete and submit the following form. Our adminstrator will contact you within three business days to place you into one of our teams.

Please note if you have filled out the self referral form and haven’t heard from our practice in 2 business days, please call the office directly at 807-622-2229.

Contact Form

Content Form

Your Name*
Your Email Address*
Home Street Address
Primary Daytime Phone Number
Alternate Daytime Phone Number
Evening Phone Number
Date of Birth
DD slash MM slash YYYY
Health Card Number
Health Card Version
Family Doctor
Obstetrician
First Day of Your Last Menstrual Period
DD slash MM slash YYYY
Expected Date of Birth
DD slash MM slash YYYY
How was your pregnancy confirmed?
How was your pregnancy confirmed?
- Home Test
- Urine Test
- Other
How many previous pregnancies have you had?
How many children do you have?
Names of previous midwives?
If you are a repeat client of Community Midwives, when was your last baby's date of birth?
Previous birth locations?
Previous birth locations?
- Home
- Hospital
- Other
How did you hear about Community Midwives?
How did you hear about Community Midwives?
- Repeat Client
- Friend
- Family
- Doctor
- Other

Midwifery care in Ontario is free and easily accessible.

Please complete our online ‘Request A Midwife’ form or call us directly at (807)-622-BABY.

Community Midwives of Thunder Bay

1119 Victoria Avenue East (top floor)
Thunder Bay, Ontario, P7C 1B7

admin@communitymidwives.net Phone: (807)622-2229 Fax: (807)628-8889