Specialist Referral Form

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Specialist Referral Form

Please fill out this form if you have a patient / client that would benefit from my support.

Please be aware, all patient information provided is kept confidential within my privacy compliant EMR, to include this intake form.

Thank you in advance!

Brittany Edwards

MSN, APRN, CPNP-AC/PC, IBCLC

The Mama Coach | Smyrna/Atlanta, GA & Surrounding Area

** Please also keep in mind that at this time I am primarily providing evidence-informed education, support and assistance ~ not acting as a provider who will diagnose, treat or prescribe. I am committed to staying within my scope of practice (to include IBCLC) and collaborating with providers within a patient's treatment team, to include referring when warranted. Please do not hesitate to reach out for any further questions.

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Email *

Referring Practitioners Name *

Referring Practitioners Practice Name & Address *

Referring Practitioners Phone Number *

Patient Name

Please list parent or guardian name(s) if the patient is a minor.

Patient Gender & Pronouns (if you are aware)

i.e. Female gender, She/Her

Patient Phone Number & Email Address *

Patient DOB *

Reason for Referral

(Check all that apply)

Prenatal Care

Lactation Services ~ Prenatal Consults

Antenatal Hand Expression Workshop

Postnatal Care

Newborn Education & Assistance

Feeding (Breast, Bottle, Pumping)

Lactation Services ~ Immediate Postpartum (<2 weeks) Education

Lactation Services ~ Infant Concerns for Latching, Slow Weight Gain, ? Milk Transfer

Lactation Services ~ Maternal/Provider Concerns for Low Milk Supply

Lactation Services ~ Maternal Ductal Narrowing (Plugged Ducts), Mastitis, Etc

Tethered Oral Tissues - Conservative Approaches as well as Pre/Post Frenotomy

Bottle Aversion

Lactation Services ~ Weaning

Starting Solids

CPR & Choking Training

Sleep Consultation (up to 18months)

Altro:

Obbligatorio

Please add a brief medical history and any additional comments relevant to the referral so I can support the family to the best of my ability.

i.e. if this is for feeding support please provide last weight in clinic, baby's birth weight, what suggestions were given/previously tried, etc.

Attestation *

I attest all information provided herein is true and correct information about the patient and they have been informed of this referral and thereby granted consent toward the sharing of their health information.

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