Registration at the Birth CenterPlease enable JavaScript in your browser to complete this form.* = Mandatory FieldFirst name *Last Name *Your Date of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Health Card Number *Expiration date *Fullname of your father *Mother's maiden name *Name of your partner *Place of birth *Address *City *Province *QuébecOntarioOtherHome phone number *Preferred language *---FrenchEnglishArabicSpanishBilingualOtherTerritory *---AylmerBuckinghamGatineauHullTo be determinedWork phone number *Postal Code *Other phone numberFirst day of last menstrual periods *Number of previous pregnancies *Number of previous miscarriages and abortions *Expected date of delivery determined by ultrasound (if applicable) *Number of previous births *Previous C-sections *How many times have you received midwifery care in the past? *---01234567Not in OutaouaisPreferred location for appointments *---Maison de Naissance de GatineauCLSC AylmerPlease specify where *Preferred midwife 1 *---No preferenceBayarova, Tobi-LynnBehruzi, RoksanaBouadel, KaoutarBouchard, MarièveDeslauriers, KimDumais, MartineFiliou-Chénier, GabrielleAlexandre OtisLéonard, JulieLévesque, MireilleLupien-Dufresne, ÉloiseMakhzani, ParvinMorin, Marie-PierSalemi, ParisaToure, AidaTurbide, Marie-ClaudeSara-Michelle BreseeMagalie BockPreferred midwife 2 *---No preferenceBayarova, Tobi-LynnBehruzi, RoksanaBouadel, KaoutarBouchard, MarièveDeslauriers, KimDumais, MartineFiliou-Chénier, GabrielleAlexandre OtisLéonard, JulieLévesque, MireilleLupien-Dufresne, ÉloiseMakhzani, ParvinMorin, Marie-PierSalemi, ParisaToure, AidaTurbide, Marie-ClaudeSara-Michelle BreseeMagalie BockPreferred midwife 3 *---No preferenceBayarova, Tobi-LynnBehruzi, RoksanaBouadel, KaoutarBouchard, MarièveDeslauriers, KimDumais, MartineFiliou-Chénier, GabrielleAlexandre OtisLéonard, JulieLévesque, MireilleLupien-Dufresne, ÉloiseMakhzani, ParvinMorin, Marie-PierSalemi, ParisaToure, AidaTurbide, Marie-ClaudeSara-Michelle BreseeMagalie BockAny additional informationWould you like to attend an information session (English based on demand only) *---yesnoHow did you hear about La Maison des naissances and its services? *---CISSS de l'Outaouais websiteFacebookSomeone I knowMedical ClinicCLSCA community organizationPromotional leafletOtherSpecify *Submit