Registration Form

Client Details: The breast/chest feeding parent
Prefix
Mr/Mrs/Miss/Ms/Dr
Full Name

First NameLast Name
Pronouns
He/She/They
Parent's Date of Birth
Contact Number
Address

Line 1

Line 2

TownCity

Post Code
Accessibility issues
E.g. Parking issues/costs, closed gate, flat access
E-mail
GP Surgery Details

Name of doctor

Street address/practice

TownCity

Post Code
Reason for Consultation
Why are you requiring IBCLC assistance
*Maternal* History
Please share maternal details such as number of pregnancies, number of children, type of birth etc
Current/Past medical issues
Please share any relevant medical history. E.g. previous breast surgery, thyroid issues, hormone issues, fertility issues, surgery, current medications...
Baby's Details

For twins pleae input both together with twin 1 details before twin 2.
Baby's Name(s)

First NameLast Name
Baby's Date of Birth
Birth Weight in KG
Kg
Latest Weight and When?
E.g. Kg on 01/01/22
Gestation at Birth
Example: 38+5
Health Visitor Name and Contact number
If you're unsure please type "unsure".
Any Other Health Professional's Details/Contact number
E.g. paediatrician, inftant feeding team. If you're unsure please type "unsure".
Baby's Medical *History*
E.g. hospital/neonatal admission, congenital anomaly, surgery, allergies, medications, previous tongue tie assessment/treatment etc
Baby's *Current* Medical Status
E.g. medications, paediatrician involvement, feeding plan in place etc
Please state any other issues/concerns
E.g. accessibility to the property, parking issues, disability considerations, language barriers
Where did you hear of my services?
Do you consent to me touching your baby during the consultation if needs be?
Do you consent to me touching your breasts/chest during the consultation if needs be?
Do you consent to a student observer being present at the consultation should I have one with me at the time? (I will let you know if I do)
Do you understand that information given here will be stored electronically according to EU Data Protection and Security Laws and will only be used for your clinical care and support?
Do you understand that I may need to share your information if I feel there is a concern regarding the safety of you and/or your baby and I will endeavour to tell you about said information sharing UNLESS I feel this will put you/your baby at further risk?
I have a duty of care to collaborate with the wider healthcare team about your consultation if I feel the need to liaise with them, that it will benefit your care and form a continuity of care with the wider healthcare team. Are you OK with this?
I may, with your permission, seek advice from other IBCLCs for additional suggestions which might support your care, in which case I will seek your verbal permission at the time and your anonymity will always be protected. Are you OK with this?
Do you understand that I am not a tongue tie practitioner, nor can I diagnose and treat medical problems or prescribe drugs/galactogogues. I can advise on the range of "normal" and give you up-to-date, evidence based information for you to make your own choices or I can help you make decisions based on the information you have. I can also refer you to the wider healthcare team should you need extra support.
Please Note: An email will be sent to you shortly after submitting your registration form; you may need to check your junk mail file for this.
Signature

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Client Details: The breast/chest feeding parent

Baby's Details