Name *

First Name

Last Name

Date of Birth *

What is the expecting parent's date of birth?

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Due Date

If you are currently pregnant or adopting a newborn, please enter the estimated due date.

MM

DD

YYYY

Lactation Information *

Have you ever breastfed, chestfed, nursed or pumped milk for your baby/babies before?

Yes

No

Have you ever been diagnosed with an endocrine disorder? *

Check all that apply. If "other", please specify.

PCOS (polycystic ovary syndrome)

Hypothyroidism

Hyperthyroidism

Diabetes

Pre-Diabetes

Hypertension

Hormonal Imbalance

Other

None

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/babies (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 the lactation consultant once my baby/babies arrive, and with progress reports, questions or concerns 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.

I consent

I do not consent (appointment may be cancelled as a result)