*** Please print and complete in ink ***
Baby’s Last Name____________________________ First Name _______________________MI___
Date of Birth_______________________ M___ F___
Baby’s Birth Weight ____ lb. ____ oz. Discharge Weight _____ lb. _____ oz.
Recent Weight______ lb. _____ oz. Date ________________
Mother’s Last Name____________________________ First Name_________________________MI___
Date of Birth ________________ Occupation ________________________________________________
Other parent’s Last Name___________________________ First Name_____________________MI___
Date of Birth _______________ Occupation ________________________________________________
Street Address __________________________________________________________________________
City, State Zip ___________________________________________________________________________
Phone Number: Mother___________________________ Other parent _________________________
Baby’s health care provider:_____________________________________________________________
Street Address, Suite #__________________________________________________________________
City, State Zip __________________________________________________________________________
Phone ______________________________ Fax_____________________________
Mom’s prenatal provider:_________________________________________________________________
Street Address, Suite #___________________________________________________________________
City, State Zip ____________________________________________________________________________
Mom’s insurance company__________________________ policy/group number_______________
Baby’s insurance company__________________________ policy/group number_______________
Phone ______________________________ Fax_____________________________
Referred By: ___________________________________________________________________________
Why have you requested this consultation?
________________________________________________________________________________________
________________________________________________________________________________________
I give my consent to Gale N. Touger, RN, IBCLC to observe me breastfeeding, to examine my breasts during the period of lactation assistance, and to examine my baby, including within the mouth, as needed to assess feeding. I understand that all diagnosing and prescribing is to be provided by my prenatal and pediatric health care providers.
I grant permission to Carolina Lactation Consultants, LLC to share pertinent information about this consultation with my/our health care providers, the referring person, my/our community breastfeeding helper, my/our insurance companies and to further the knowledge of breastfeeding.
____________________ ___________________________________________________________________ Date Signature of Mother
____________________ ___________________________________________________________________ Date Signature of IBCLC
