Lactation Counselor Intake Form

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Maritday Rodriguez, CLC
Certified Lactation Counselor
For Lactation services & online support groups, please complete this form
You will receive a response in as little as 1 hour and not more than 12 hours.
For urgent matters, please call/text my cell phone. 978-480-0773

Email *

If you have a fever, suspect mastitis, or have an emergency, contact your Midwife or Doctor or go to the emergency room before filling out this form.

Today's Date *

YYYY

Name *

Phone # - If you prefer a phone call back: *

Skype Name (for video call or outside of USA) *

Baby's Name *

Baby's Gender *

Female

Male

Prefer not to say

Other:

Baby's Birthday or Estimated Due Date *

YYYY

Birth Weight *

Describe the problem you are having: *

I am interested in: (Please check all that apply.) *

Column 1

Making an appointment for a Lactation Consultation

Add me to MHV Breastfeeding Facebook Group

Attending the MHV Breast-milk Circle

Breastfeeding Newsletter

I am interested in more information about: *

Column 1

Sore Nipples

Plugged Ducts

Mastitis

Too much milk

Slow weight gain in baby

Green Stools

Tongue or Lip Tie

Baby refuses to breastfeed

Sleepy Baby

Client’s Responsibilities:

• I will communicate my needs to the CLC as her duties will depend on my concerns and needs that day.

• If I am unable to keep my appointment with the CLC, I agree to give the CLC at least 24 hour notice. If I do not, my deposit will NOT be returned to me or applied to fees.

• In the event of illness, emergency or severe weather, every effort will be made to reschedule services as soon as I am aware that I cannot keep our appointment. Payment for that day will be applied to future service if already paid.

Cancellation of Service:

• Please notify me 24 hours in advance if you need to reschedule a day of service to avoid a $50.00 late-cancellation fee. This fee does not apply in the case of a true emergency or severe weather condition cancellations.

• If you decide for any reason (other than a hospitalization of the mom/baby) that the signed upon services are no longer needed, you are still responsible for the full dollar amount of this contract, because I have put aside said time for your family and no one else’s.

• I will notify you 24 hours in advance if I need to reschedule service for that day due to an illness. If I am called away, I will make every effort to provide a back-up CLC for you. If you waive the back-up CLC or one is not available on short notice, I will be sure to reschedule your time for another day within 48 hours.

Signature

Submitting this form is proof of your inquiry and that you understand our booking and cancellation policy.

A copy of your responses will be emailed to the address you provided.

Submit

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