Client Intake Form Copy

This is a TEST Intake Form

Your privacy is important to us. Thames Valley Midwives will not share or sell your information with anyone else.


Uninsured?  Please read!

If you are a landed immigrant, a refugee claimant, a resident with an expired Ontario Health Card, or a permanent resident without an Ontario Health Card, and you do not have health insurance, you are eligible to access funding for uninsured Midwifery clients.  You may be required to cover costs associated with your care such as laboratory/diagnostic fees, physician services, home birth costs, and/or hospital fees.  Participants in this program will need to share their names with our transfer payment agency in order for the government of Ontario to pay for services you utilize while in Midwifery care. 

If you are not a resident of Canada (a visitor, tourist, or a student), do not intend to stay in Canada, and will be leaving Canada after the birth of your child, you are not eligible to access our funding program for uninsured clients of Midwifery.

Please do not call our office regarding this submission – we will contact you if and when a spot becomes available. In the meantime, please continue to see your family physician or your current care provider. Thames Valley Midwives will only contact you if a spot becomes available.

NOTE – please add Thames Valley Midwives to your email address book and check your spam/junk email account for a reply from our office. We will often notify you if a spot becomes available by email.