Registration and Consent Form

*** 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