Shadowing Inquiry

In the past 14 days, have you or anyone in your household experienced or been in close contact with someone who has ANY of the following symptoms: fever, chills, coughing, fatigue (not related to having a newborn), sneezing, sudden loss of smell or taste, runny or stuffy nose, congestion, headaches, shortness of breath, difficulty breathing, sore throat, nausea, vomiting, diarrhea, or body aches and pains (not on your breasts/chest and not related to childbirth)?*

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.

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 $20 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