Email and Virtual Consult Request Form
Email and virtual consults are for general breastfeeding advice and for issues which do not require physical assessment. If I feel that your question warrants a physical assessment, I will let you know and we can work from there.

Email consults are for you if you have a pain free latch, and a generally content baby who is gaining weight appropriately (between 5-7 ounces a week up until 4 months and between 3.5-5 ounces per week from 4-6 months) with no major concerns over you or baby's health and do not need to be physically seen.  Non-clinical issues include starting solids, pumping schedules, going back to work, questions on newborn behavior and frequenct, etc.

Virtual Consults follow the same guidelines, but are for issues where visuals are needed, such as flange fit, or where clinical assessment is needed (clogged ducts, oversupply, low supply when exclusively pumping, etc).
Sign in to Google to save your progress. Learn more
Email *
Your name *
Your Date of Birth *
MM
/
DD
/
YYYY
Baby's Name *
Baby's Date of Birth *
MM
/
DD
/
YYYY
Your email address *
Non-refundable deposit of $50 is due at the time of submitting this form. Email consults are $125. Virtual consults are $200. Both include one week of follow up. Additional weeks are charged at $25 a week. You will be given a balance after your form is reviewed and consult will commence after balance is paid in full. You can pay through venmo at @KiraKimIBCLC or via PayPal at accounting@northshorebirthservices.com Venmo is preferred. Please initial here to signify that you agree with these terms. *
Primary Insurance (I will email you the form to file for reimbursement). All fees are due upfront during our session. Please note, if you have Aetna, you must see an Aetna provider. Please don't fill out this form. Text me at 617-319-4542 to discuss. *
Please choose which service you would like.  If you are unsure, I will help you choose after I receive your form. *
Required
Medical History
Age of first period *
Were your periods regular before becoming pregnant (meaning relatively even cycles regardless of length): *
Do you have a history of any of the following conditions? *
Required
Do you have a personal or family history of breast cancer?
Clear selection
Do you have a family or personal history (both parents) of orthodontia, speech impediments or gaps between the front teeth?
Clear selection
Have you ever had surgery on your breasts (biopsy, implants, breast lift, breast reduction, lumpectomy?) -If so, please explain the procedure, how long ago it was and the reason it was performed *
Do you have or have you been told you have any abnormalities to your breasts? Marked difference in size (A vs C cup for example), tubular shape, very wide spacing, etc. *
Have you ever sustained an injury to your ribs or spine? *
List any current medications (include supplements, herbs, and over the counter medications)?
Pregnancy and Prior Breastfeeding Questions
How many pregnancies have you had? *
How many live births have you had (over 24 weeks)?
How old are your other children?
Was this child conceived through assisted reproductive technology (including but not limited to IUI, IVF, etc)
Clear selection
Did your breasts changed in any of the following ways during this pregnancy? *
Required
Have you breastfed before? *
If you have breastfed before, did you experience difficulties with any of the following:
If you are worried about baby's weight, how has your baby's weight gain been in the past month? If you have actual weights, that would be great.
Please describe your concern or question in detail. Include how long the issue has been going on for, what makes it worse or seems to help, and how it is affecting your nursing relationship. If you have questions on gear, be specific on brands and types. The more information, the better. *
What questions do you have for me in regards to your concern?  What is your immediate goal? Longer term goal? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Boston Area Lactation Connection. Report Abuse
Google Forms