Lactation Consultation Intake Form
This form is to be filled out by the lactating parent. Please answer these questions ahead of in-person or virtual sessions to ensure Tara Daystar IBCLC can provided you with the best care and service possible. These questions are important to help the LC understand the big picture and provide accurate care. While some of these questions are not "required", I encourage you to fill out as many as possible. This google form is HIPPA protected.  Thank you!
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Email *
Parent's name (first and last) *
Parent's phone number: *
Husband/Partner/Support Persons name(s)
Parent's home address (Consult with take place in your home unless you state another preference): *
Insurance type/name. *
Please provide names of: OB/Midwife and Pediatrician *
Baby(s)'s name(s) (first and last) *
Baby(s) date(s) of birth *
MM
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DD
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YYYY
Baby(s)'s birth weight *
Gestational age of baby(s) at birth
Please describe if this is your first child or if you have other children and their ages and whether they breastfed for any length.
In your own words, please describe the reason for this consult and what you have tried, if anything, to resolve the issue(s) of concern: *
How did you hear about New River Lactation and/or Tara Daystar?
Do you, the lactating parent, have a history of
What type of delivery did you have with this birth? *
Required
Did you have any of the following with this birth? *
Required
Did your baby(s) have any health issues after birth? *
Does your baby/toddler currently have any health problems? If twins, please address each child. Please include any medications they are taking
Are you taking, or have you recently taken/used, any of the following? *
Required
Did your breasts grow during pregnancy? *
Required
Have you noticed breast changes since birth? If so please describe. *
If you have a pump, what type of pump?
Has your baby(s) been supplemented with expressed breastmilk or formula? If so, please describe. write N/A if not applicable. *
How frequently do you breastfeed (and or pump for) your baby(s) and for how long? Ok to give a range ex. x-y min every z hrs.
Are you experiencing any of the following? *
Required
In the past 24 hours, how many total wet diapers and total dirty diapers? If twins, specify for each.
How long do you wish to breastfeed and/or provide pumped milk to your baby(s)? *
Please describe any accommodations that could make the lactation consultant more helpful & easeful for you. Otherwise, write N/A *
Please sign and date to certify that the information you have provided is true and correct to the best of your knowledge. Virtual signature and/or initials are ok. *
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