Booking Form

Booking Form

This form takes about 5 minutes to complete. Please make sure to complete all of the required fields.
Client Preferred Name
Name*

First NameLast Name
Client Date of Birth*

DayMonthYear
Date
Occupation
Address*

Street Address

Street Address Line 2

TownCounty

Post Code
Contact Number*
Please enter a valid phone number.
Email*
example@example.com
How did you hear about us?
Baby's information
Baby's Name*

First NameLast Name
Baby's Date of Birth*

DayMonthYear
Date
What feeding support do you require?*

Are there any access or parking arrangements that we may need to be aware of before visiting?
Please ensure that all pets are put away prior to the arrival of the Lactation Consultant. Thank you for your understanding.
Health Care Professionals
GP Name*
GP Address*
Midwife or HV name*
MW of HV contact details*

Consent
I understand that:

All medical care is to be provided by my GP and Midwife or Health Visitor and any change from their recommendations should be discussed with them
A consultation with an IBCLC may include examination of the breasts, the baby's mouth, an observation of a breastfeed, demonstration of techniques and equipment to improve breastfeeding and a care plan to treat breastfeeding issues which may be adjusted over time.

Students may occasionally accompany the IBCLC, you will be advised of this and have the right to decline
I am responsible for informing the Lactation Consultant of any changes in the breastfeeding situation.

I grant consent that:

Information about this consultation can be shared with my GP or other Health Care Professional
Information, photographs, and/or video from this consultation to be used for teaching purposes, with the understanding that no names or identifying features will be used.
Treatment will be given according to the scope outlines above.
East Sussex Early Days CIC can hold and process my data. Data will be stored securely until the baby reaches the age of 25, it will then be safely destroyed.
East Sussex Early Days CIC can contact me by phone or email for the purposes of following up on this consultation.
Signature

Clear
Should be Empty: