Forms | Drops Of Hope Lactation And Wellness Consulting

Once you have confirmed an appointment with me, please complete all fields prior to your phone or in-home Lactation Consult

Mom's Full Name

Mom's Date of Birth

Mom's Age

Mom's Profession

Street Address

City

State

Zip code

Phone

Partner's Name

Partner's Profession

How did you hear about this service?

Baby's Full Name

Baby's Date of Birth

Weeks Gestation at Birth

Facility of Birth

City/State of Birth

Obstetrician/Midwife

City

Phone

Pediatric Provider

City

Phone

I understand that:

Initials

All medical care is to be provided by my own physician/provider(s) and that any change from his/her/their recommendations should be discussed with him/her/them.
A lactation consultation by the IBCLC may include a visual and manual assessment of the mother's breasts/chest, the baby's mouth and suck, observation of mother and baby breastfeeding, analysis of information relating to the breastfeeding situation, demonstration of techniques for improving breastfeeding, use of breastfeeding equipment, and recommendations of a care plan to resolve breastfeeding issues, which may be adjusted during the course of treatment.
A student intern may accompany the IBCLC and participate in the consultation from training purposes.
I am responsible for informing the lactation consultant of any relevant information or changes that affect my breastfeeding situation.
It is my responsibility to notify the lactation consultant with progress reports, questions or concerns.
Payment for services and supplies are my sole responsibility and required at the time of service. A receipt will be provided for possible insurance reimbursement.

I grant consent for:

Information about this consultation to be mailed, faxed, emailed or verbalized to my attending healthcare provider(s) and/or pertinent referrals.
Information about this consultation to be used for teaching purposes, with the understanding that no names or identifying features will be used.
Treatment according to the scope of practice outlined above.

Initials

I agree to the terms and conditions outlined above.

Your Signature

Today's date

Thank You!

Your form has been submitted.

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