Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Lactation Consultation Intake Form
Your information
Parent / Mother Information
Parent Date of Birth
____ / ____ / ________
Phone Number
Baby Name & Date of Birth
Email Address
Birth Details & Delivery Method
Current Feeding Method & Schedule
Feeding History & Supplementation
Additional details
Current Breastfeeding Concerns
Maternal Health History
Current Medications & Supplements
| Medication | Dose | How often |
|---|---|---|
Known Allergies
| Allergy | Reaction |
|---|---|
Insurance Information
Carrier
Member ID
Group number
Subscriber name
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Signature
Date
Lactation Consultation Intake Form template from formisoft.com. formisoft.com/intake-templates/lactation-consultation-intake