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BirthWorx Lactation Referral Form
We will contact your client directly to book a homevisit as soon as possible. We may contact you first if more details are needed. Thank you for your referral!
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Lactation Consultant Information
Name
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Client Information
Name
*
Your answer
Address
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Baby's Name
*
Your answer
Baby's Date of Birth
*
MM
/
DD
/
YYYY
Current Healthcare Provider Name and Location
*
Your answer
Urgency of Referral
*
Urgent (within 24-48 hours)
Semi-urgent (within 3-4 days)
Non-urgent (within 1 week)
Reason for Referral
Please check all that apply
Latching difficulties
Nipple pain/damage
Thrush treatment
Tongue tie assessment and frenotomy as needed
Low milk supply
Mastitis
Other:
Strategies Tried to Date
Please provide details of your assessment, recommendations and current feeding plan
*
Your answer
Baby's birthweight
*
Your answer
Most recent weight
*
Your answer
Client's Medical History
Relevant maternal health history
*
Your answer
Type of delivery
Uncomplicated vaginal birth
Vacuum/forceps assisted vaginal birth
Cesarean section
Clear selection
Current medications and medication allergies
Your answer
Any other details you would like to provide?
Your answer
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