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Ready to book? Please fill out this pre-appointment questionnaire to get started. If you're not sure about booking yet and just have a question, please see my contact information below.
Email
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Mother's Name
*
Baby's Name
Date and Time of Birth
Year
Month
Month
Day
Time
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Hours
Minutes
Gestational Age at Delivery
Birth Weight
What is your main concern or reason for accessing lactation services?
Maternal Health History
Please check all that apply
Breast augmentation
Breast reduction
Breast or nipple abnormalities
Thyroid issues
Diabetes
Hypertension
PCOS
Other
Newborn Health History
Please check all that apply
Hypoglycemia
Jaundice
Birth trauma (including forceps, vacuum)
Birth defect
Other
Please provide any relevant information based on selected issues.
Additional Information
Partner’s name
Mother’s Health Care provider
Baby’s Health Care provider
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