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
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Referring Provider NPI
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Provider Contact Phone
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Patient Name
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First Name
Last Name
Patient DOB
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/
Month
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Day
Year
Date
Referral for:
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Mother
Baby
EDD
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Month
/
Day
Year
Date
Delivered?
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Yes
Not yet
Date of Delivery
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Month
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Day
Year
Date
Baby's Birth Date
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Month
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Day
Year
Date
Parent or Guardian Name
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Patient Contact Phone
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Patient Insurance
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Insurance Member ID
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Insurance Group
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Urgency:
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Emergent (within 24 hours)
Urgent (within 72 hours)
Routine (within 1-3 weeks)
Reason for maternal referral:
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Prenatal planning
Routine postpartum consult
Breastfeeding pain
Low milk supply
Engorement
Mastitis
Other
Reason for infant referral:
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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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