Health Provider Referral Form
OHIP-Covered Breastfeeding Consultations
Referring Health Provider Details
Full Name
*
First Name
Last Name
Designation
MD
NP
Midwife
OHIP Billing #
*
Phone Number
-
Area Code
Phone Number
Patient Details
Breastfeeding Parent Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
OHIP #
*
Please include version code
Baby Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Birth Weight
*
Date of most recent weight
*
-
Month
-
Day
Year
Date
Most recent weight
*
Sex
Male
Female
OHIP #
*
If OHIP number not available put "NA". Include version code if available.
Lactation Consultant
Lactation Consultant Preference
Tori Hamilton, RN, IBCLC, PMH-C (Kincardine/Online)
Claire Dolmage, RPN, IBCLC, CBE (Stratford/Online)
Lindsay Law, RN, IBCLC (Port Elgin/Online)
Soonest Available
Reason for Referral
Date
-
Month
-
Day
Year
Date
Signature of Health Provider
*
Clear
Submit
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