New Patient Registration (Form 1 of 3; Lactation

New Patient Registration (Form 1 of 3; Lactation - General)

Please complete this DEMOGRAPHIC INFORMATION to register as a new patient at Family Care, PA. These questions have been modified from our standard New Patient forms to better prepare for lactation consulting services at your first visit. Required fields are marked with a Red Asterisk. After you submit this form, you will be transferred to a second form to complete your Health History information. This is the 1ST OF 3 times you will complete a form, sign your name, and hit Submit before you will have completed your New Patient Registration.
Breastfeeding Patient Questions

These questions are specific to the adult that will be breastfeeding their infant.
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Patient's Cell Phone Number*
###-###-####. Please enter a landline, if you do not have a cell phone.Format: (000) 000-0000.
Patient's Email Address*
Email you would like to use for our Patient Portal.
Patient's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the Patient's GENDER?
What is the Patient's SEXUAL ORIENTATION? You may select more than one.

AsexualBisexualGayStraight / HeterosexualLesbianPansexualQueerQuestioning / UnsureIdentity Not ListedPrefer Not to Disclose
What is the Patient's MARITAL STATUS? You may only select one.

SingleMarriedDivorcedSeparatedOther
What is the Patient's ETHNICITY?*
What is the Patient's SPEAKING LANGUAGE? You may select more than one.*

EnglishSpanishOther
What is the Patient's EMPLOYMENT STATUS? You may select more than one.

Employed, Part-TimeEmployed, Full-TimeStudent, Part-TimeStudent, Full-TimeDisabled, TemporaryDisabled, PermanentUnemployedRetiredOther
Patient's Emergency Contact

First NameLast Name
Patient's Emergency Contact Phone
###-###-####Format: (000) 000-0000.
Patient's Relationship to Emergency Contact*
eg. Parent, Brother/Sister, Friend, Spouse, etc.
Which PHARMACY would you like to use as your default pharmacy?*
What is your selected PHARMACY'S PHONE NUMBER?*
###-###-####Format: (000) 000-0000.
Which HEALTH INSURANCE PROVIDER covers the Patient's medical services?*

Blue Cross Blue ShieldCignaUnited HealthcareAetnaMedicareUninsuredOther
What is the Patient's SUBSCRIBER ID NUMBER?*
You may skip this, if you are able to provide a photo copy of your insurance card below.
Infant Questions

These questions are specific to the infant that will be breastfed by the adult listed above.
Infant's Name

First NameLast Name
Infant's Birth Weight (lbs)
Infant's Discharge Weight (lbs)
Infant's Most Recent Weight (lbs)
How many weeks gestation was baby at birth?
In the past 24 hours, how many times has baby eaten AT BREAST?
In the past 24 hours, how many times has baby eaten FROM BOTTLE?
In the past 24 hours, how many times has baby eaten from ANOTHER FEEDING DEVICE?
Was baby born by vaginal delivery or c-section?
Were there any complications during or after the birthing process? If so, what?
Has baby had any illnesses/medical conditions? If so, what?
Lactation Questions

These questions are specific to your lactation or re-lactating needs.
Why do you need a lactation consultation?
What do you know about inducing lactation/re-lactating?
Have you seen a lactation consultant or any other specialists about feeding (e.g.,infant feeding/speech therapist, ENT, dentist, or other bodyworker)? If so, please list:
What resources (if any) have you used to learn about inducing lactation/re-lactating?
Do you have a lactation consultant? If so, who?
Please mark the following options, if they apply.

I would like to produce some milk for my baby.I would like to feed baby my breast milk, exclusively.I would like to pump my breast milk and bottle-feed it to the baby.I would like to nurse at the breast / chest.I would like to nurse at the breast / chest, with a supplementer.I would like to feed a combination of my breast milk and donor human milk, if needed to supplement.I would like to feed a combination of my breast milk and formula, if needed to supplement.I would like to feed baby at the breast / chest without inducing lactation or re-lactating.
Will anyone other than you be providing breast milk for the baby? If so, who?
Do you have any fears or concerns about inducing lactation or re-lactating?
What do you envision in your journey of breastfeeding, chest feeding, and/orother forms of infant feeding? Do you have any specific goals or wishes?
When was your FIRST menstrual period?
When was your LAST menstrual period?
Have you ever been pregnant? If so, when? What were the outcomes? Any complications?
Are you currently pregnant?
Are you doing anything to prevent pregnancy?
Have you previously breastfed, chest fed, and/or induced lactation? If so, describe your experience. Is there anything you would like to be different this time?
Will anyone other than you be providing breast milk for the baby? If so, who?
Upload a photo (.jpg, .gif, or .pdf) of the FRONT AND BACK OF THE PATIENT'S INSURANCE CARD. You will need to provide this before your appointment.

Cancelof
If completing this form for someone else, what is YOUR NAME?

First NameLast Name
What is YOUR RELATIONSHIP to the Patient?*

I am the Patient.My child is the Patient.My parent is the Patient.My friend is the Patient.Other
I, the undersigned, certify that the information provided on this form is accurate and truthful. If I intend to claim insurance benefits for services rendered at Family Care, I certify that the insurance coverage I have provided is accurate and truthful. In exchange for providing and billing these services to my insurer, I assign directly to Family Care, PA all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I, the Responsible Party named below, am financially responsible for all charges that have been duly processed through my insurance and still assigned to patient responsibility. I hereby authorize the doctor to release all information necessary to secure payment of my benefits. I authorize the use of this signature on all insurance submissions and claims for medical services provided by Family Care.
Please verify that you are a human being.*
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New Patient Registration (Form 1 of 3; Lactation - General)

Breastfeeding Patient Questions

Infant Questions

Lactation Questions