Kids Corner Feeding Clinic Referral Form

Kids Corner Feeding Clinic Referral Form

Dr. Alex Hernandez MD. FRCPC // www.kidscorner.ca // email form to taya_vw@hotmail.com
Please note that this Feeding Clinic Referral Form needs to be completed by your family doctor (referrals for virtual feeding appointements are not accepted from midwives) .Once completed the Referral Form can be sent via text (416-996-0321) or email (taya_vw@hotmail.com).
Referring Physician Details
Name (Dr.)

First NameLast Name
Billing Number
Date of Referral

MonthDayYear
Full Address (include postal code)
Phone Number
Fax Number
Provider Signature

Powered by Jotform SignClear
Infant's Details (please provide separate referrals for multpiles)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address
Sex
Health Card Number / VC
Lactating Parent Details (all details are required)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address
Health Card Number / VC
Sex
Email (to be used for booking purposes)
Phone Number (to be used for booking purposes)
Family Doctor Name
Family Doctor Contact Details
Reason for Referral

Please either check box with an (X) or provide more details.

*Indicates maternal issues directly related to feeding concerns which impact weight gain overall nutrition and an infant's wellbeing.
Latching Concerns
Including sore nipples / shallow latch
Slow Weight Gain
Colic / Reflux
Tongue tie (Oral concerns)
Pumping and Bottle Feeding Questions
Flange sizing
Introduction to Solids
Weaning
Need for Supplementation (Breast milk / Formula)
Low Milk Production*
Breast / Nipple Pain*
Previous Breast Surgery*
OTHER
Should be Empty: