Registration at the Birth Center * = Mandatory Field First Name* Last Name* Email* Your date of birth* Health Card Number* Expiration date* Full name of your father* Mother's maiden name* Place of birth (province or country)* Name-partner* Address* City* Province* QuébecOntarioOther Territory* ---AylmerBuckinghamGatineauHullTo be determined Postal Code* Home phone number* Work phone number* Other phone number Preferred language* ---FrenchEnglishArabicSpanishBilingualOther First day of your last menstrual period* Expected date of delivery determined by ultrasound (if applicable)* Number of previous pregnancies* Number of previous births* Number of previous miscarriages and abortions* Previous c-sections* How many times have you received mdwifery care in the past ?* ---01234567Not in Outaouais Please specify where * Preferred location for appointments * ---Maison de Naissance de GatineauCLSC Aylmer Preferred midwife 1* ---No preferenceBayarova, Tobi-LynnBehruzi, RoksanaBouadel, KaoutarBouchard, MarièveDeslauriers, KimDumais, MartineFiliou-Chénier, GabrielleHendi, Seyedeh RobabLéonard, JulieLévesque, MireilleLupien-Dufresne, ÉloiseMakhzani, ParvinMorin, Marie-PierSalemi, ParisaToure, AidaTurbide, Marie-Claude Preferred midwife 2* ---No preferenceBayarova, Tobi-LynnBehruzi, RoksanaBouadel, KaoutarBouchard, MarièveDeslauriers, KimDumais, MartineFiliou-Chénier, GabrielleHendi, Seyedeh RobabLéonard, JulieLévesque, MireilleLupien-Dufresne, ÉloiseMakhzani, ParvinMorin, Marie-PierSalemi, ParisaToure, AidaTurbide, Marie-Claude Preferred midwife 3* ---No preferenceBayarova, Tobi-LynnBehruzi, RoksanaBouadel, KaoutarBouchard, MarièveDeslauriers, KimDumais, MartineFiliou-Chénier, GabrielleHendi, Seyedeh RobabLéonard, JulieLévesque, MireilleLupien-Dufresne, ÉloiseMakhzani, ParvinMorin, Marie-PierSalemi, ParisaToure, AidaTurbide, Marie-Claude Any additional information Would you like to attend an information session?(english based on demand only)* ---yesno How did you hear about la Maison des naissances and the services offered there ?* ---CISSS de l'Outaouais websiteFacebookSomeone I knowMedical ClinicCLSCA community organizationPromotional leafletOther Specify *