Jackie's Breast Friends

Jackie's Breast Friends
New Client Intake Lactation History, Privacy Acknowledgment & Consent
Welcome! Please complete this form before your appointment. It takes about 5-7 minutes. Everything you share is kept confidential. If a question doesn't apply to you, leave it blank.
1. Your Information
Name

First NameLast Name
YOUR DATE OF BIRTH

MonthDayYear
Date
PHONE NUMBER
Format: (000) 000-0000.
EMAIL ADDRESS
example@example.com
MAILING ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PREFERRED CONTACT METHOD
EMERGENCY CONTACT NAME
EMERGENCY CONTACT PHONE
Format: (000) 000-0000.
HOW DID YOU HEAR ABOUT US?
2. Your Baby
BABY'S NAME
BABY'S DATE OF BIRTH

MonthDayYear
Date
BIRTH WEIGHT
CURRENT WEIGHT (IF KNOWN)
GESTATIONAL AGE AT BIRTH (WEEKS)
SINGLE OR MULTIPLES
PEDIATRICIAN NAME/CLINIC & Fax number
3. Pregnancy & Birth
TYPE OF DELIVERY
ANY PREGNANCY OR BIRTH COMPLICATIONS? (LEAVE BLANK IF NONE)
Jackie's Breast Friends IBCLC Lactation Support Salt Lake City, UT 385-313-8301
Page 1

Rows	FEEDINGS PER 24 HOURS	AVERAGE LENGTH OF A FEEDING	WET DIAPERS / DAY		DIRTY DIAPERS / DAY
1

USING A BREAST PUMP?
IF YES, WHAT KIND?
USING BOTTLES OR FORMULA?
IF YES, HOW MUCH PER DAY?
PAIN DURING FEEDING (0 NONE - 10 SEVERE)
USING A NIPPLE SHIELD?
LATCH OR POSITIONING CONCERNS
6. Your Concerns & Goals
WHAT IS THE MAIN REASON FOR TODAY'S VISIT / YOUR BIGGEST CONCERN RIGHT NOW?
WHAT ARE YOUR FEEDING GOALS?
ANYTHING ELSE YOU'D LIKE ME TO KNOW?
Jackie's Breast Friends IBCLC Lactation Support Salt Lake City, UT 385-313-8301

7. Acknowledgment of Privacy Practices (HIPAA)
I acknowledge that I have been given the opportunity to review the Notice of Privacy Practices for Jackie's Breast Friends. This Notice describes how my protected health information (PHI) may be used and disclosed, and how I may access that information. I understand I may request a copy of the Notice at any time. I also understand the practice may update the Notice and will make the current version available upon request.
PLEASE CONFIRM
PRINTED NAME

First NameLast Name
DATE

MonthDayYear
Date
SIGNATURE (YOU WILL SIGN ELECTRONICALLY IN JOTFORM)
8. Consent for Lactation Services
I voluntarily consent to receive lactation consultation and support services from Jackie Burgett, IBCLC of Jackie's Breast Friends. I understand that lactation consulting provides education and support and is not a substitute for medical care from my physician, my baby's pediatrician, or other licensed providers, and that I should contact those providers for medical concerns. I agree to share accurate and complete health information so that care can be provided safely.
Financial responsibility: Payment is due at the time of service. The in-home consultation fee is $160 for a 90-minute visit; an additional $25 travel fee applies outside Salt Lake & Utah counties. A superbill can be provided for me to submit to my insurance; I understand reimbursement is not guaranteed and is between me and my insurer.
Cancellation: I understand I should give as much notice as possible if I need to reschedule or cancel.
TELEHEALTH (FOR VIRTUAL VISITS ONLY)
PHOTOGRAPHS (OPTIONAL — YOUR CHOICE)
PLEASE CONFIRM
PRINTED NAME

First NameLast Name
DATE

MonthDayYear
Date
SIGNATURE (YOU WILL SIGN ELECTRONICALLY IN JOTFORM)
Should be Empty:

Jackie's Breast Friends

New Client Intake Lactation History, Privacy Acknowledgment & Consent

1. Your Information

2. Your Baby

3. Pregnancy & Birth

4. Your Health History

5. Current Feeding

6. Your Concerns & Goals

7. Acknowledgment of Privacy Practices (HIPAA)

8. Consent for Lactation Services