Name *

Phone Number *

Email *

Reason for Contact *

Name *

Phone Number *

Email *

Partner's Name *

Address *

Reason for Lactation Consultation *

Your Age *

Name of Infant *

Date of Birth *

Place of Birth *

Due Date or Gestational Age at Birth *

Birth Weight *

Discharge Weight *

Last MD Weight and Date *

Supplementation - how much & how often? *

Any Medical Conditions and Medications or Herbals - Mother *

Any Medical Conditions and Medications - Infant *

History of Breastfeeding Challenges/Breast Surgeries *

Please list any breastfeeding tools/supplies you are using to assist feedings? *

Do you have a breastpump and what brand and model? *

Plans to go back to work/school and continue breastfeeding? If yes, in how many weeks/months? *

Attend breastfeeding support groups? Where? *

Name of health insurance company *

Pediatrician - Name & Contact Information *

Obstetrician/Midwife - Name & Contact Information *

What is the best way to contact you and when? *

What kind of contact do you utilize? *

Do you regularly have access to the internet so that I may send you information (only pertaining to our consultations and follow-ups)? *