Client Intake Form

Clinic Reception Hours

To book appointments, our administrative staff can be reached during the following hours.

Monday – Thursday: 9:00am – 4:30pm

Tel: 519-664-2542

Email: birth@stjacobsmidwives.on.ca  

Mailing address:
St. Jacobs Midwives
P.O. Box 190
9 Parkside Drive, Unit 2
St. Jacobs, Ontario, N0B 2N0

Please note: Our service area includes (parts of) Kitchener, Waterloo, and Woolwich Township as well as parts of Wellesley and Wilmot Townships

Fax: 519-664-1815

Pregnant and looking for care? Contact us as soon as possible to check for availability.

If you are interested in becoming a client of St. Jacobs Midwives, please complete Intake Form below. When our administrator calls you within 3-5 business days, they will record more detailed information. Due to high demand, space is limited and may not be guaranteed.

Please be aware that any information sent on a form (email) may not be secure. Any information you provide will be stored in accordance with our Privacy Policy and the privacy standards for Ontario.

St Jacobs Midwives Client Intake Form

If you are interested in becoming a client of St. Jacobs Midwives, please complete our Intake Form.

"*" indicates required fields

MY CONTACT INFORMATION

As shown on my Ontario Health Card or other legal documents:
As shown on my Ontario Health Card or other legal documents:
The name I prefer to be called.
Pronouns

MM slash DD slash YYYY
The language I speak at home most of the time:
I can be reached at:
Telephone Message
Is it okay to leave a message at the above phone number?
Address*
Please note: Our service area includes Kitchener, Waterloo, and Woolwich Township as well as parts of Wellesley and Wilmot Townships

MY DETAILS

Are you a resident of Ontario for at least 12 months?
What is your status in Ontario?
Do you have a valid Ontario Health Card?
Do you anticipate moving in the next 9 months?
Have you had midwifery care before?
How did you hear about us?

Do you know the first day of your last menstral period?*

MY CONSENT

Ministry of Health Data Collection*
May we share your information with the MOH? The Ministry of Health (MOH) is collecting data about the demand for midwifery care in Ontario. This information may help get more midwives to our area. Your information is kept confidential.
Consent*