Welcome

Outreach Midwifery Self-Referral Form

By providing your email you agree that GRCHC may contact you using your email for the purpose of providing information regarding specialist appointments, diagnostic testing or information related to our upcoming programs, clinics, and events at GRCHC. You understand that GRCHC cannot guarantee the security of email messages. You understand that email messages may pose a risk to your privacy. You understand at this time, messages from GRCHC will not allow for any email response from you.

Admin Staff Use Only : D __ Date: MS___ Date:

Name:

Date of birth (mm/dd/yyyy)

Address

City

Postal Code

Email

Phone Number

Pronouns

They/Them

He/Him

She/Her

Baby's Name

Baby's Date of birth (mm/dd/yyyy)

Baby's Address

Services Requested (please check any that apply):

Lactation Consultant Care (any age baby breast/chest feeding with issues) We can help with any problems you are having with feeding. For example, sore nipples, latch problems, baby not gaining weight well. We weigh babies and provide support and medical advice around feeding issues.

Midwifery Postnatal Care (for parent or baby) We can provide medical care for you and your baby for the first 6 weeks after birth.

Midwifery Prenatal Care (Midwife will arrange referral to Obstetrics for delivery care) We can provide medical care as soon as you realize you’re pregnant. We order ultrasounds and bloodwork and give advice and support. We are not on call and don’t deliver babies.

Birth Control Counselling and Prescribing We can give you information about your options and can prescribe all forms of birth control.

IUD/Nexplanon Insertions or Removals We can insert or remove IUDs or Nexplanon (which is a hormonal implant placed in your inner upper arm)

Pap Tests We can perform Pap tests for you and copy the results to your Doctor.

Priority for booking you for our services will be given to the populations listed below; however, please feel free to request our services if you are do not fall into the populations below and we will book you in if we have space.

Priority Populations: (please check any that apply)

People with Mental Health Diagnoses and/or Addictions

People with No housing or Precarious Housing

Newcomers *(International Students – refer to your School’s Health Care Programs)

People under the age of 26

2SLGBTQIA+

People from Low Income Households

IBPOC (Indigenous, Black, Person of Colour)

Please indicate if there is additional information you would like the healthcare provider to know or if you are interested in other health services:

We will notify you as to whether we can accommodate your referral within a maximum of 7-10 business days.