Consent for Lactation Services

Please understand that as a lactation consultant I can not give medical advice. If the breastfeeding problem appears to be medical, I will have to refer you to your physician or pediatrician. To better serve your needs, please fill out this form completely and type your name at the bottom.
Mother's Name:
Father's Name:
Married Single Divorced
Mother's Date of Birth:
Street Address:
City:
 State: Zip:
Email Address:
Phone Number:
Best Time to Call:
What is the nature of the problem you are having?
Baby's Name:
Baby's Date of Birth:
Delivered at (name of hospital or birthing center):
Any medications currently taking?
If so, please list:
Does mother or baby have any health problems? If so, please list:
Has themother had any breast augmentation or reduction?
Tell me about your birth experience.
Was it long, short, hard, traumatic, easy?
Pediatrician's Name:
Phone Number:
Obstetrician/Midwife's Name:
Phone Number:
Who referred you to us?
Please enter your initials here to digitally sign this form:
Today's Date: