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Ask for a Midwife

To request midwifery care, you can call our office or fill out this form online.  By filling out this form you are asking for care from a midwife and agreeing to allow us to collect this information.  Within approximately one week we will contact you to let you know if we are able to care for you. Any information you provide will be stored in accordance with our privacy policy and the privacy standards for Ontario (privacy code).

Please be aware that we cannot guarantee the security of your private information while it is in transit by email. If you have any concerns about sending personal information via email, please feel free to call our office (519-763-8568) and talk to us directly.

Personal Information

Please review our privacy policy before filling out the form.

Privacy Statement from Family Midwifery Care

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Pregnancy Information





Information about other pregnancies

How many times have you given birth?

Partner Information (if applicable)

A bit more information...

Note: The Ministry of Health is collecting data on the demand for midwives. May we have your consent to share your information? This information could help get more midwives in the area.