Apply For CareFill out an application for care Consent * For use by Midwifery Practice Groups to obtain verbal consent from unaccommodated clients to collectand disclose personal information The Ministry of Health and Long-Term Care — which provides funding for the Ontario Midwifery Program — would like to obtain information on the demand for midwifery services around the province. To help the Ministry get the information it needs, we have agreed to ask individuals we are unable to be accommodated at our Practice Group whether they would be willing to provide some basic personal information and consent to the disclosure of this information — specifically, name, birth date, postal code, and expected date of birth. This information will be collected through the Better Outcomes Registry and Network (BORN), a prescribed registry that collects information related to maternal, infant and child health. BORN also administers the Midwifery Invoicing System on behalf of the Ministry. The Ministry needs this information in order to properly conduct a study that will assist in future planning for midwifery services across the province. You should know that: You will be notified within 7- 10 business days by phone or email regarding your intake form. The Ministry will not receive your personal information and will only receive de-identified, aggregated data; BORN will receive your personal information only if you consent to this disclosure; you are under no obligation to provide this information, and if you do not consent, this will have no effect on your eligibility to receive midwifery care in the future; and BORN, on behalf of the Ministry is collecting this information solely for the purpose of conducting a study to assess the demand for midwifery services in the province, and will use it for no other purpose. Do you have any questions? Would you be willing to provide your name, birth date, postal code, and expected date of birth to give us your consent to enter this information into BORN? [Midwives of Windsor] If you later have any questions or concerns about us collecting or disclosing this information, don't hesitate to call us back at 519-252-4784. Thank you so much for your help. Yes No Name (as it appears on your health card/government ID) * First Name Last Name What pronouns do you prefer? she/her, he/him, they/them, or other pronoun Email * Phone Number * (###) ### #### Can we leave a voicemail * Yes No Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Do you have OHIP insurance? * Yes No If no, do you have other insurance This could be from another province, private insurance, refugee, etc. First day of your last menstrual cycle? * MM DD YYYY Estimated Due date * MM DD YYYY Was it a 28 day cycle? * Yes No Have your had 3 months of regular periods? * Yes No Is this your first pregnancy? * Yes No How many children do you have? Are you currently breastfeeding? * Yes No Have you had an ultrasound? * Yes No Due date given by ultrasound MM DD YYYY Do you have any medical problems? Yes No If yes, please explain Are you taking any medications Yes No If yes, please explain Have you had problems in a previous pregnancy? Yes No If yes, please explain Have you had a midwife previously? Yes No If yes, who was your Midwife? Do you have a Health Care Provider, if so who? This could be your family doctor, Nurse Practitioner, or walk-in clinic you use frequently Do you have an obstetrician? Where do you plan on having your birth * It is ok if you don't know yet, we have plenty of time to figure that out. Home Hospital Unsure Why are your interested in Midwifery care? Who referred you? Is there anything else you want us to know? Thank you for your application. We will call to confirm your information within 1-5 business days.
