Request Care If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Your full name: * What is your date of birth? (d/m/y) * What is your email address? * By checking this box, I agree Generations Midwifery may contact me by email. Home Address: * City: * Postal Code: * Primary Phone Number: * By checking this box, I agree Generations Midwifery may leave voicemail in my primary phone number mailbox. Alternate Phone Number: By checking this box, I agree Generations Midwifery may leave voicemail in my alternate phone number mailbox. What is your estimated due date 'EDD'? What was the first date of your last menstrual period 'LMP'? (Will be used to help determine EDD): If you are uncertain about your LMP, how did you come about calculating this EDD? Is this your first pregnancy? Choose one ... Yes No Have you received midwifery care before? Choose one ... Yes No Are you currently receiving prenatal care? Choose one ... Yes No Who is your family doctor (or other primary health care provider)? Do you have a valid Ontario health card? Choose one ... Yes No What has brought you to midwifery care? Anything else you'd like us to know? For the purposes of our waiting list (to provide the Ontario Ministry of Health with information about the needs of midwifery consumers so it can better serve them), in the event that we are not able to offer you care, would you consent to giving your name, date of birth, and postal code to the Ministry? By checking this box, I consent to my name, date of birth, and postal code being shared with the Ministry of Health and Long Term Care.