“ Professional Lactation Support at Your Doorstep or Online “

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Lactation Consultant Visit

Patient Intake Form

Thank you for scheduling a visit with a Lactation Consultant (LC). To ensure the best possible care during your telehealth or in-person consultation, please complete this form prior to your appointment. This information helps your LC understand your concerns and health history to provide personalized support.

General Information

Preferred Contact Information

Primary Concern

Examples: Difficulty latching, milk supply concerns, pain while nursing, etc.

Medical and Feeding History

Parent's Health History
Infant's Health History

Feeding Information

How often is your baby feeding?
Every _____ hours for approximately _____ minutes per session.

Goals and Expectations

Acknowledgment

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge.

Welcome to our online telehealth business! We are dedicated to helping mothers who face challenges with breastfeeding.

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