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Service Information

Service:

Midwifery Care
Organization: The Midwives' Clinic of East York-Don Mills
Description:

You do not need a referral from a doctor to have a midwife; please book a time to speak to our midwifery care team. We take clients of all ages and backgrounds!

If you require a language that we do not offer in our clinic, we are happy to coordinate translation services for you.

Our care is free of charge -- OHIP and health insurance are not required.

The midwives at TMC are a diverse group that includes queer, transgender, racialized, Muslim and Jewish midwives, midwives who were not born in this country and midwives’ whose first language was not English. We welcome and celebrate the diversity of our practice and strive to provide affirming care to all our clients. We do not tolerate discrimination of any kind towards our midwives, staff, or other clients.

Referral Options:

I have read and understood the Zero Tolerance statement above.:*

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Is it ok to leave a voicemail?*

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Have you been to our clinic before?*

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If you have been to our clinic before, please indicate the year and the name of your prior midwife:

If you've used a midwife from another clinic, please indicate the most recent year you were cared for:

If other, please explain:

While we cannot guarantee you will be assigned to a specific midwife, please let us know if you have a preferred midwife:

Please check the box if you prefer a female care provider for religious reasons or cultural reasons. Please note that we cannot guarantee your request

Preferred Birth Location:*

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How did you hear about us?

Has anyone helped you to fill out this form, or are you filling out the form on behalf of someone?

Applicant Information

Applicant Name:

First name*

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Family/Last Name*

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Personal Pronouns:

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Email Address:*

Email (Confirmation and reminder emails will be sent here)

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Phone:

Primary Phone*

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Secondary Phone

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Address:

Unit/Suite #

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Street # & Street Name*

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City*

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Province/State*

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Postal/Zip Code*

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Date of Birth:*

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Month

Year

Age: ( corrected)

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The age eligibility requirements for this service is:

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Applicant Health Card Number:*

Applicant Health Card Number*

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Language:

What is the preferred Language?

English

French

Other

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Family Doctor:

Family Doctor Name

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Family Doctor Phone #

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Does the registrant grant permission to referral recipient to contact the family doctor for more information?

Yes

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Partner / Support Person

Partner / Support Person Name:

First name

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Family/Last Name

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Prenatal Care Provider (if applicable)

Prenatal Care Provider (if applicable) Name:

First name

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Family/Last Name

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Prenatal Care Provider (if applicable) Info:

Primary Phone

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Health Information

Reason for Referral:

Please share more about why you are seeking a midwife for your pregnancy

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Allergies:

Please list and describe any allergies

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Medications:

List all medication, and dosages per day

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Pregnancy:

When is your due date?

yyyy-mm-dd

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Relevant Medical History:

Please include any other relevant medical history, especially if you have had complications in previous births.

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Home Visit Information

Nearest Intersection:

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Parking Instructions:

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Door Entry Code:

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Home Risks:

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Dog

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Additional Information

If your period is not a regular 28 day cycle, please describe your cycle:

What was the FIRST day of your most recent period?:

Leave blank if you are unsure of your last period date:

How many times have you been pregnant? (including this pregnancy):*

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How many times have you given birth?:*

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If you have previously had a caesarean, what was the date?:

Have you had a previous vaginal birth?:*

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Is there anything else you'd like to tell us about your current pregnancy or previous births?:

Do you have plans for pain medication during your birth?:

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By clicking "Finish", you agree to send this personal information to The Midwives' Clinic of East York-Don Mills online.

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Notifications:

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Summary

Reference #: -

Registrant:
Organization:

The Midwives' Clinic of East York-Don Mills

Service:

Midwifery Care

Inquiry Phone:

1 (416) 424-1976

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