LA Fire Virtual Lactation Consult

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Please complete the form in its entirety prior to your virtual lactation consult.

*please include as much detail as possible *

Full Name *

Email (this will be used to send you a care plan after the visit)

Baby’s Name *

Baby’s Due Date/Birthday *

YYYY

What is your biggest concern for today’s meeting? Feel free to add as much detail as needed. *

Have you had any other following (and please explain below) *

Breast Surgery (Biopsy, Augmentation, Reduction)

PCOS

Thyroid Issues

Any other major diagnosed medical condition

NONE

Other:

Required

Has your baby been diagnosed with any issues such as tongue tie, lip tie, jaundice, glucose issues, etc? Please explain *

What does your living situation currently look like and what resources do you have? Manual Pump, electric pump, access to bottles, clean water, etc.

In exchange for this consult, would you be willing to leave a review on Ashley's google after the visit? *

Yes, I would love to!

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