Infant Intake Form

PREGNANCY AND LABOR HISTORY:
Was your pregnancy routine or high risk?
Birth Location (which hospital, birth center or home birth)
Birth

VaginalCesarean/C-Section
Gestational age at birth
Any additional stressors with labor?

Long Labor/Excessive PushingBreech BirthUnplanned C-SectionTrauma from Vacuum or ForcepsOther
Additional comments?
Difficulty with latch after birth?

YesNo
If yes, please explain:
Other breastfed children/how long?
If you swaddle your infant, how often?

MODE OF FEEDING
Mode of Feeding (Check all that apply)

BreastBottlesBreast and bottlesPumped breastmilkDonated breastmilkFormulaSupplemental Nursing SystemI am not nursing or pumpingLactation has recommended a "triple feeding" schedule of nursing, bottle feeding and pumping
How often are feeding sessions?
How long do feeding sessions last?

IN YOUR OWN WORDS
In a sentence or two, please share your current concerns:
In a sentence or two, please share your feeding goals:
How satisfied are you with your current feeding experience?

1

2

3

4

5

1 is Unsatisfied, 5 is Very Satisfied
What are your expectations/what are you hoping to achieve?

MEDICAL INFORMATION RELEASE FORM (HIPAA RELEASE FORM)
PATIENT NAME

First NameLast Name
PATIENT DATE OF BIRTH

MonthDayYear
Date
I hereby authorize Dr. Shannon Thorsteinson and affiliates, employees, or agents to release any personal health information (e.g., information relating to the diagnosis, records, treatment, claims payment, and healthcare services) to the following named individuals for the purpose of collaborative care:
PARENT/SPOUSE/RELATIVE
REFERRING PROVIDER
PEDIATRICAN
LACTATION CONSULTANT
OCCUPATIONAL THERAPIST
BODYWORK PROVIDER/DOULA/MIDWIFE/ADDITIONAL PROVIDERS
If unable to reach me:

You may leave a detailed messageYou may leave a message asking me to return your call
PARENT/GUARDIAN COMPLETING FORM

First NameLast Name
Signature*

Clear
Date

MonthDayYear
Date
This release of information will remain in effect until terminated by me in writing.

TREATMENT FEE SCHEDULE

Fee For Service

Dear Patients and Parents,

Thank you for choosing our practice for your healthcare needs. We greatly appreciate your trust and confidence in our expertise and consider it an honor and privilege to help you and your family. We chose to build a patient-centered model for our practice that does not allow insurance companies to dictate the care we provide. This means that we are not contracted with insurance carriers. Because of this, we collect payment directly from the patient during the time of your visit. Our office does, however, provide what you with what you will need in order to send the claim to your insurance company. Your insurance company may reimburse you directly according to the terms of your policy. Our consultation, procedure, and follow-up service fees are in accordance with the following schedule. Because we desire to keep our service affordable and understand the increasing burden of healthcare expenses, our policy is to cap the maximum costs to our families at $1,000 per patient.

Below is a breakdown of care we provide and its related cost to you:

Procedure	Fee
Office Consultation	$250
Tongue Tie release	$375
Lip tie release	$375
Check tie release and two post op appointmens	No charge

We hope this information provides clarity and reassurance to you about our billing practices. Please let us know if there are any additional questions or concerns.

I have read the above information and have had the opportunity to seek answers to any remaining questions. I further understand that I will not be reimbursed for services covered by my insurance company that were not charged to me as the responsible party.

PARENT/GUARDIAN COMPLETING FORM

First NameLast Name
Signature*

Clear
Date

MonthDayYear
Date

LATE CANCELLATION NOTICE
PATIENT NAME

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date
We honor our patients’ time, as well as that of our team. When we create your appointment, we reserve a room to assess your needs, prepare your records, as well as specialized instruments for your visit. We ask that if you must change an appointment, please give us at least 24 hours notice. This courtesy makes it possible to give your reserved room to another patient in need.

There is a $100 charge for missing scheduled appointments or cancelling appointments within 24 hours. Repeated cancellations or missed appointments will result in loss of future appointment privileges.
PARENT/GUARDIAN COMPLETING FORM

First NameLast Name
Signature*

Clear
Should be Empty:

	Yes	No
all recommended vaccines
any heart conditions/diseases
any prior surgery to correct the tongue or lip tie
any other surgeries
acid reflux diagnosed by a pediatrician
jaundice

INFANT INTAKE FORM

INFANT'S MEDICAL HISTORY

PREGNANCY AND LABOR HISTORY:

INFANT'S SYMPTOMS

MODE OF FEEDING

Breastfeeding Questions

IN YOUR OWN WORDS

MEDICAL INFORMATION RELEASE FORM (HIPAA RELEASE FORM)

This release of information will remain in effect until terminated by me in writing.

TREATMENT FEE SCHEDULE

LATE CANCELLATION NOTICE

	Yes	No
seem satisfied/content after a nursing session?
require supplementation after a breast feeding session?