Parent's Name
*
First Name
Last Name
Parent's Date of Birth
*
Please enter the date of birth of the lactating parent
MM
DD
YYYY
Email
*
Phone
(###)
###
####
Child(ren)'s Name(s)
*
First Name
Last Name
Child(ren)'s Date of Birth
*
or, if expecting, due date
MM
DD
YYYY
Child(ren)'s Birth Weight(s)
*
How much did your baby/babies weigh at birth?
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Any special parking instructions? (for in-home visits only)
If you live in a gated community or if there are any special parking instructions, please describe here:
Pregnancy Information
If you had any complications during this most recent pregnancy, please describe here:
Birth Information
Check all that apply
Additional Birth Information
Please describe your birth in detail. Breastfeeding can be affected by your birth experience, so please share any details you feel are pertinent.
Prior Breastfeeding Experience
Have you ever breastfed/chestfed/pumped your milk for other children? Please describe.
Type of Visit
In-home Lactation Consult
Virtual Lactation Consult
In-office Lactation Consult
Reason for Visit
Please explain why you are seeking the help of a lactation consultant. What is your primary concern?
Current Parent Issues
What issues/challenges are you currently facing?
Current Child Issues
What issues/challenges is your baby currently facing?
Other issues
Are there any other difficulties we should know about?
Have you ever had any breast surgeries?
Reduction, Augmentation, Lumpectomy, etc
Breast surgery description
If you have had any surgery to the breast/chest, please describe. (If you've ever required an incision to the chest, even as a child, please explain)
Have you ever been diagnosed with an endocrine disorder?
Check all that apply. If "other", please specify.
Other medical condition or endocrine disorder
Please specify any medical conditions
Medications and/or supplements
Are you currently taking any prescription or over-the-counter medications or supplements? (Please include any lactation teas, tinctures or foods.)
Insurance Information (if you are covered through The Lactation Network, you may skip these next 6 insurance questions).
Federal guidelines specify that insurance companies must cover comprehensive lactation support and counseling from a trained provider. Will you need assistance working with your insurance company to cover your consult or get reimbursed?
Insurance Company Name
If you answered "Yes" to the previous question, please provide your health insurance company's name
Insurance ID Number
What is the ID number on your insurance card?
Insurance Group Number
What is the Group Number on your insurance card?
What is your relationship to the insurance subscriber?
Please select one
Consent for Lactation Care
*
Please check one of the boxes indicating whether or not you consent to the following lactation care practices:
I give my consent for the lactation consultant to work with me and my baby (if born) during this consultation for my breastfeeding concerns. This consent is for in-person and virtual visit, a well as phone conversations, and any information or communication sent via email, mobile phone. SMS text messages and/or private social media conversations.
I understand that electronic/cellular forms of communication may not be encrypted or secure. Initial consultations include a follow-up email and calls/text messaging for up to three weeks.
I understand that a lactation consultation MAY involve:
- touching my breasts/chest and/or nipples for the purpose of assessment
- inserting a gloved finger into my baby's mouth to assess suck and oral mobility
- observation of a feeding or pumping session, and suggestions made to enhance latch/positioning
- demonstration and use of equipment or supplies that may be recommended
- demonstration of techniques designed to improve breastfeeding
I understand that partial follow-up visits are sometimes necessary.
I understand that breastfeeding supplies and/or breast pumps may be recommended as effective management of specific situations.
I understand that I am responsible for informing the lactation consultant of changes that I feel are necessary in the care plan at the time of our visit or during the course of follow-up communications.
I understand that it is my responsibility to call/text/email is the lactation consultant with progress reports, questions or concerned as I see fit.
I understand that clinical information related to this consultation may be shared with my insurance company and other health care providers in accordance with HIPAA regulations.
I understand that for this lactation consultations and for any/all follow-ups, the lactation consultant will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners, and the Standards of Practice of the International Lactation Consultants Association.
