Clinic Intake Form

Please fill out the below Intake form and book an appointment with one of our professionals at our partnership clinic location.

Referral Information

How were you referred to us? (Friend/Family, Social Media, Clinician, Community Org, Other):Friend/FamilySocial MediaClinician or Other ProfessionalClinic or Community OrganizationOtherReferee Information:Role (e.g., OBGYN, Midwife, Nurse, Doula, Social Worker, etc.):Referring Professional Name:Referring Professional Phone Number:Organization / Clinic / Community Organization:If 'Other', please specify:

Personal Information

First Name:Last Name:Preferred Name:Date of Birth:Pronouns:Languages Spoken:Email Address:Cell Phone:Home Phone:Home Address:Do you identify as: Black / Indigenous / Person of Colour / Racialized / None:

Pregnancy Information

Currently Pregnant?YesNoEstimated Due Date or Infant Birth Date:Pregnancy Complications & Medications:Urgent? (Care needed within 24 hours)YesNoAdditional Information (urgent care):

Service Information

Subscribe to Newsletter? (Yes / No):YesNoLocation:Service Referral (select all that apply):LactationPelvic Floor TherapyDental HygienistDoula CareChildcareBirth Location (Hospital / Home / Birth Centre / Other):If hospital, which hospital?:Ethnic / Cultural Background (optional):Queer community? (Yes / No):YesNoTrans / Non-binary identity? (Yes / No):YesNoFurther describe sexual orientation / gender identity:If parent, how many children?:Doula Support for (Prenatal / Labour / Postpartum / Feeding / Miscarriage / Abortion / Loss Support):If abortion anticipated, clinic appointment date:Doula Identity Preferences (language, cultural background, lived experience, etc.):Doula Training / Teachings preferred:Care preferences / notes:What would you like to discuss with Maternal Health Navigator?:Additional Experience Details:

Additional Contact / Medical & Consent Details

Gender:Emergency Contact Name:Emergency Contact Phone:Family Doctor:

Consent to Tele-Rehabilitation:

I consent to participate in tele-rehabilitation. I understand the benefits, risks, and alternatives. I may withdraw consent at any time.

Signature:Date:

Dental / Oral Health Questions

Covered by Dental Plan / Program? (Yes / No):YesNoIf yes, which (ODSP / OW / Private / Healthy Smiles / Other):If Other, specify:Request for self? (Yes / No):YesNoRequest for dependent? (Yes / No):YesNoRelationship to dependent:Number in need of service:Names and ages of those needing care:Preferred Service (Home / Office / Virtual):Concerns to discuss with Dental Hygienist:

Fertility / Doula / Other Support

What type of fertility support are you seeking?:Doula care needs:

Thank you! Your submission has been received! Please read our terms and conditions below:

Please click here to view our terms and conditions

Mino Care has partnered with North York General Hospital. On select dates, we’ll offer services at their clinic space at 2 Champagne Drive—book same-day visits with our full team. On-site childcare is available to make your visit easier. Please use the buttons below to book an appointment. Please note Childcare must be booked seperately.

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Clinic Intake Form

Please fill out the below Intake form and book an appointment with one of our professionals at our partnership clinic location.

Referral Information

Personal Information

Pregnancy Information

Service Information

Additional Contact / Medical & Consent Details

Consent to Tele-Rehabilitation:

I consent to participate in tele-rehabilitation. I understand the benefits, risks, and alternatives. I may withdraw consent at any time.

Dental / Oral Health Questions

Fertility / Doula / Other Support

Thank you! Your submission has been received! Please read our terms and conditions below:

Care Services

Resources for Parents

Research & Advocacy

About Us

Clinic Intake Form

Please fill out the below Intake form and book an appointment with one of our professionals at our partnership clinic location.

Referral Information

Personal Information

Pregnancy Information

Service Information

Additional Contact / Medical & Consent Details

Consent to Tele-Rehabilitation:I consent to participate in tele-rehabilitation. I understand the benefits, risks, and alternatives. I may withdraw consent at any time.

Dental / Oral Health Questions

Fertility / Doula / Other Support

Thank you! Your submission has been received! Please read our terms and conditions below:

Care Services

Resources for Parents

Research & Advocacy

About Us

Consent to Tele-Rehabilitation:

I consent to participate in tele-rehabilitation. I understand the benefits, risks, and alternatives. I may withdraw consent at any time.