Lactation Intake form

Confidentiality Clause: This information will not be shared with anyone without your consent.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email

How do you prefer to be contacted?

Phone

Email

Baby's Name

What is your baby's birth date?

MM

DD

YYYY

Was your baby considered full term at birth?

Yes

No

What did your baby weigh at birth?

Has your baby had any other weights taken? If so, what was the most recent weight?

Are you a first time parent?

Yes

No

What are your breastfeeding goals?

Briefly state why you are requesting lactation support.

Are you experiencing pain? If so, where?

Are you feverish or experiencing changes in the appearance of your breast? *Please note: If you are experiencing high fever, please reach out to your medical provider.

Anything else you would like me to know?