Shadowing Inquiry

Luna Lactation Shadowing Inquiry Form
When shadowing in our practice, we ask that you not be ill or have had serious illness in your home for 14 days before shadowing. Can you agree to this term?*

YesNo
Are you fully vaccinated for COVID-19?*

YesNo
Please upload a picture of your COVID-19 vaccination card*

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Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Profession and/or credentials*
Why do you want to shadow with Luna Lactation?*
What lactation education have you already completed or plan to complete?*
What are your goals?*
What amount of hours do you need?*
What are your preferred days/times to shadow?*
By signing below, I am agreeing to the following:
- I understand that Luna Lactation typically charges $30 per shadowing hour.
- I agree to behave professionally at all times.
- I understand that shadowing is observing, not participating, in clinical care.
- I understand that I must comply with the rules of HIPAA.
Signature*

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Luna Lactation Shadowing Inquiry Form