Consent For Care Form (Required to Book First Visit with Baby)
- Ontario Breastfeeding Clinic -

Hi, from Natalie & Emma - OBC Admin : )

We are looking forward to helping you reach your lactation goals very soon!

The fastest way to book a Lactation Consult is to take 10 minutes now to fill out this form.  

Completing this now will let us get you booked in and will save you a lot of time in your visit, so we can start right away with your concerns.  

Once submitted we will save your place on the waitlist for the next available appointment and send you our WELCOME EMAIL.  

Commencing Feb 29th, 2024, each appointment with a physician requires a valid referral, OHIP, and $77.00 + HST ($87.01) to cover the fees of the International Board Certified Lactation Consultants which are not covered by OHIP. This fee must be received via e-transfer to physician@ontariobreastfeedingclinic.ca prior to booking.  Please remember to add your name to the memo so we know where to apply your fee : )

Private Pay with an IBCLC Lactation Consultant (not associated with the physician group) is also an option available to you.  NO referral or OHIP is required.   Private-Pay Virtual Consult (IBCLC only) $120.00 (+HST) = $135.60 CAD.  Private-Pay In Person Office Consult (IBCLC only) $150.00 (+HST) = $169.50 CAD. 

Please text the command PRIVATEPAY to our admin line BEFORE submitting payment.  

This fee must be received via e-transfer to privatepay@ontariobreastfeedingclinic.ca prior to booking.  Please remember to add your name to the memo so we know where to apply your fee : )

Some private insurance companies cover lactation support under a health care spending account and others need a doctors note.  Please check with your individual policy to determine your level of coverage. You will receive a receipt after your visit which you may submit to a private insurance company. 

Please make your service selection below.
Wishing you a free hand to fill out this form!

Warmly, Natalie & Emma - OBC Admin

OntarioBreastfeedingClinic.ca
Monday - Friday 9am-5pm, Closed STAT Holidays.

Need help?  Please contact our admin team by
TEXT ONLY 1-877-822-1105
admin@ontariobreastfeedingclinic.ca

PS. Don't forget to hit SUBMIT, or I will not receive it!  Thank you :  )
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Email *
Please Select an IBCLC/Location
Please select your preferred visit type
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Lactating Parent's Information
Parent's First Name (as on Health Card) *
Last Name (as on Health Card) *
Preferred Name (first and last, if different from above)
Mobile Phone ONLY *
Parent's Address
Street Address *
Unit #
City *
Postal Code *
Province *
Country *
Parent's Date of Birth *
MM
/
DD
/
YYYY
Sex (Please ensure the sex you provide here matches your Health Card Information) *
Gender (Refers to current gender which may be different than what is indicated on your insurance policies or medical record)
Pronouns (if you wish to share)
Parent's Health Card Number (10 digits) *
Parent's Health Card Version Code (2 letters after digits on plastic card) *
Parent's Health Card Expiry Date *
MM
/
DD
/
YYYY
Occupation
Emergency Contact
Emergency Contact Relationship
Emergency Contact Phone
Family Dr: *
Family Dr's Contact/Location
Name of Referring Provider (Ontario Based) *
Referring Provider Details *
Referring Provider's Contact/Location
How did you hear about us?
Clear selection
Baby's Information
More than one baby?  Please complete a new form for Baby A, then Baby B etc. 
How many babies are you breastmilk feeding (or planning to)?  Select all that apply *
Required
Baby's First Name *
Baby's Last Name *
Baby's Sex at Birth *
Baby's Due Date during Pregnancy *
MM
/
DD
/
YYYY
Baby's Birth Date *
MM
/
DD
/
YYYY
Baby's Weight at Birth (lbs+oz OR kg/g) *
Baby's Most Recent Weight Check Date *
MM
/
DD
/
YYYY
Baby's Most recent Weight (lbs+oz OR kg/g) *
Baby's Health Card Number (10 Digits on slip of paper from birth) *
Baby's Health Card Version Code (two letters after number on plastic card.  "N/A" if not yet received) *
Baby's Health Care Provider(s).  Full name of Midwife, family dr and/or Nurse Practitioner if different from yours.  Please tell us who to contact to request a referral for baby. *
And now for the heart of the story... 
Questionnaire: Your IBCLC would love more information to help you reach your goals
You are invited to share as much information as possible with your IBCLC using this next section.  It's ok if you don't know, or the answer changes, or you can't answer all the questions!  

Just do your best, and PLEASE REMEMBER TO HIT SUBMIT at the end of this form.  

Thank you!

Warmly, Your IBCLC
Ontario Breastfeeding Clinic
What is your current feeding goal?
Is your baby usually content or sleeping between feedings?
Longest time between DAY TIME feeds
Longest time between NIGHT TIME feeds
Do you schedule feeds or feed baby "on cue" or both?
When breastfeeding, does the baby drink from both breasts at every feed?
Baby's Output

Number of wet diapers in the last 24 hours
Number of soiled diapers in the last 24 hours
Are the baby's stools soft?
What colour are the baby's stools?
Is baby currently getting Vitamin D supplementation?
Clear selection
Is your baby in good health?  If not, please tell us more
Clear selection
Do you currently supplement your baby with expressed breastmilk or formula?
If you are Supplementing Baby
If not, please skip to LACTATION CONCERNS
How often does your baby get supplement milk in a 24 hour period?
If supplementing, how much milk do you currently need to offer baby?
When does baby get supplemented? (click all that apply)
Do you currently use any of the following support tools?
Lactation Concerns
Common Concerns:  Check all that apply

Do you currently have any of the following? 
Yeast concerns: check all that apply
Supply concerns: check all that apply
Letdown reflex concerns: check all that apply
Other concerns: check all that apply or tell us more
Parent Health History (Required)
History of past (including pregnancy, birth) or current conditions (select all)
 *
Required
Are you currently taking any medications?  Yes/No

If yes,  please list here:
 *
Are you currently taking any herbs or supplements?  Yes/No 

If yes,  please list here:
 *
Family History (check all that apply to your immediate family)
 *
Required
Number of pregnancies
 *
Number of live births
 *
How many weeks pregnant were you (the birthing parent) when baby was born?  Gestational age at birth
Birth History
During the birth we experienced
If You Pump or Hand Express
If not, skip to CONSENTS
If you have/rent a breast pump, what kind?
How many times a day do you pump?
Do you pump one or both breasts at each session?
How many minutes do you pump per breast?
How much milk to you produce when pumping? (average guess is ok!)
Consents (Required)
Accuracy of Information
 *
Required
Email and Text Communication

I opt to receive emails and texts to keep informed of new bookings, changes to bookings, and reminders for upcoming appointments.
 *
Required
Privacy and Sharing of Information

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring provider as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission. Finally, I understand and agree to allow students of lactation medicine to participate in my care provided I grant my consent at each visit. Should I elect to use text messaging or email to communicate with the organization, I understand that these methods of communication are not secure in nature. Further, I understand that there are limitations to the complexity of care provision available to me and my child(ren) related to virtual care. I agree to seek further in depth clinical support where indicated and as directed by the consulting providers.
 *
Required
Special Request to "Pay it Forward"

At the OBC we have unique opportunities to help families, today and in the future. 

Please consider saying yes to receiving very occasional invites to upcoming lactation surveys.  

Your participation helps our researchers study lactation in Ontario, and hopefully helps create Change for Good in the future of lactation support worldwide.  

Thank you : )
Cancellation Policy:  Please play nice : )

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the practitioners’ day that could have been given to another patient. 
As such, we require 48 hours notice (2 full business days, not including weekends or holidays) for any cancellations or changes to your appointment.  If you cancel or reschedule your appointment less than 48 hours in advance, as outlined above, we are unable to provide a refund.  All refunds are subject to a $20+HST processing fee.

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