Lactation Referral
Thank you for your referral. Please fill out separate forms for mother and infant if both require referral. Call the office at 207-352-4113 with concerns.
Referring Provider
*
Referring Provider NPI
*
Provider Contact Phone
*
Format: (000) 000-0000.
Patient Name
*
First Name
Last Name
Patient DOB
*
/
Month
/
Day
Year
Date
Referral for:
*
Mother
Baby
EDD
*
/
Month
/
Day
Year
Date
Delivered?
*
Yes
Not yet
Date of Delivery
*
/
Month
/
Day
Year
Date
Baby's Birth Date
*
/
Month
/
Day
Year
Date
Parent or Guardian Name
*
Patient Contact Phone
*
Format: (000) 000-0000.
Patient Insurance
*
Insurance Member ID
*
Insurance Group
*
Urgency:
*
Emergent (within 24 hours)
Urgent (within 72 hours)
Routine (within 1-3 weeks)
Reason for maternal referral:
*
Prenatal planning
Routine postpartum consult
Breastfeeding pain
Low milk supply
Engorement
Mastitis
Other
Reason for infant referral:
*
Excessive weight loss
Poor weight gain
Can't latch/ remain latched
Birth injury
Torticollis
Reflux
Ankyloglossia
Maternal pain during feeding
Needs nipple shield
Excessive fussiness
Inadequate output
Other
Referral Comments:
Clinical photos
Clinical File Upload
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Delivery, postpartum, neonatal notes; previous lactation notes; previously saved clinical photos.
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