Registration and Consent Form

*** Please Print and Complete in Ink ***

Baby’s Last Name: _______________________ First name: _____________________ M F

Date of Birth: ___________________________ Birth Weight: _________ lb. ________ oz.

Discharge Date: _________________________ Discharge Wt: _________ lb. ________ oz.

Recent weight: _________ lb. ________ oz.       Date: _______________________________

Address: ___________________________________________________________________

City, State, Zip Code: _________________________________________________________

Mother’s Last name: _____________________ First: _______________________________

Mother’s Date of Birth: ___________________ Occupation: _________________________

Other parent’s Last name: _____________________ First: ____________________________

Other parent’s Date of Birth: _______________ Occupation: __________________________

Phone: Mother: _________________________   Other parent: _________________________

E-mail: Mother: _________________________ Other parent: _________________________

Baby’s health care provider: ____________________________________________________

Address, suite #: _____________________________________________________________

City, State, Zip Code: _________________________________________________________

Phone: ________________________________ Fax: ________________________________

Mother’s health care provider: __________________________________________________

Address, suite #: _____________________________________________________________

City, State, Zip Code: _________________________________________________________

Phone: ________________________________ Fax: ________________________________

Referred by: _________________________________________________________________

Reason for referral: ____________________________________________________________

Insured’s Name__________________________________________________

Insurance Plan or Program___________________________________________

Policy Group Number_________________  Insured’s  ID Number________________

 

I grant my consent to Gale N. Touger, RN, IBCLC to observe me breastfeeding and to examine my breasts, and to observe and examine my baby during the period of lactation assistance. I understand that all medical care is to be provided by my/our own physician(s).

I grant permission to Carolina Lactation Consultants, LLC to share pertinent information about this consultation with my/our health care providers, the referral source, my community breastfeeding helper, my insurance company and as appropriate to further the knowledge of breastfeeding. 

______________________________________________________________________________________
Signature of Mother                                                                                        Date

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Signature of IBCLC                                                                                           Date

 

©Carolina Lactation Consultants, LLC                919-606-4565