New Patient Packet 

Submit new patient packets online or completed printed version prior to your inital visit. 

Families of multiples, please fill out a new form per infant. 

Patient Name *
Patient Name
Patient Date of Birth
Patient Date of Birth
Medical History
Previous Medical History
Do you have a history of any of the following? (please select if yes)
Have you had any surgery on your breast or chest?
Social History
Do you smoke now, or have you ever smoked?
Do you have any unusual stress in your life right now?
Will you be returning to paid employment?
Who lives in your home?
Do you eat a vegan or vegetarian diet?
Is anyone abusing you right now?
Have you ever been abused?
Do you feel unsafe right now?
Obstetric History
Did you breastfeed any previous children?
Have you had any miscarriages/abortions/stillbirths?
Did you require any assistance to conceive this baby?
Did you take any medications to sustain this pregnancy?
Did you experience any of the following this pregnancy:
Did your breast change during pregnancy?
Labor and Birth History
Where was this baby born?
How was this baby born?
Did you experience any of the following with this labor/birth?
Postpartum History
Did you experience any of the following after birth?
Are you currently nursing multiples or tandem nursing?
Infant Medical History
Infant Date of Birth
Infant Date of Birth
Postnatal History
Where does infant sleep during the night?
Current Concerns:
Consent & Financial Agreement
I understand the following: The lactation consultant is an allied health care provider and responsible for evaluating and recommending a care path to resolve or improve breastfeeding issues. A lactation visit includes a detailed history of mother/infant, an assessment of maternal/infant anatomy, observation of a feeding for evaluation of technique and effectiveness of feeding, and recommendations for management to improve and/or resolve breastfeeding related issues. All clients are provided with a written and/or oral care path to improve breastfeeding concerns. The client and the lactation consultant each have responsibilities in this path. Resolution of a breastfeeding problem often takes several days or weeks and may require a change in the original recommended care path at some point. I understand that I am responsible for informing the lactation consultant of changes I feel are necessary in the care path at the time of the visit or during the course of follow-up communications. Phone contact during the time following the lactation visit is crucial and considered an extension of this visit. I understand I will be given a phone number to call to report progress or to communicate continued problems or concerns. I understand it is my responsibility to call the lactation consultant with progress reports, questions or concerns. I understand any change from my physician’s recommendations should be discussed with the physician. Health care issues of a medical nature MUST be discussed with a physician. I understand a partial or follow-up visit is sometimes necessary. I understand that breastfeeding supplies and/or breast pumps may be recommended as effective management of specific situations. Only effective breastfeeding equipment will be recommended. I authorize the lactation consultant to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers, referring physician, referring lay breastfeeding counselor, and/or our insurance company upon request. I understand the lactation consultant may contact my physician or my child’s physician if the lactation consultant feels it is necessary to consult with the physician. I have received a copy of the lactation consultant’s HIPAA Privacy Practices or understand it is available on lactation consultant’s website.I understand the lactation consultant is a provider on a limited number of insurance plans and will only bill my insurance if the lactation consultant is contracted as an in-network provider with my plan. All services provided for insurance plans for which the lactation consultant is NOT a provider are fee for service at time of service.It is my responsibility to pursue reimbursement for lactation services from my insurance company when the lactation consultant is not an in-network provider on my insurance plan, in which case, full or partial reimbursement is not guaranteed.I give permission for information, photos and/or videos of my lactation visit to be used in lactation articles, case studies or other studies for professional lactation or maternal/child education. *