Real Birth Knowledge, LLC Lactation Intake Form

Thank you for choosing Real Birth Knowledge. Please complete this form to the best of your abilities prior to your lactation consultation. We are not currently billing insurance.

Visit Type:

Prenatal Consultation/Education Session

If you're interested in learning about breastfeeding and getting yourself, home, and family prepared for this journey, book a prenatal consultation.

This can take place in our office, your home, or a virtual consultation.

Complete as much information on this form as possible, we understand if you do not have all of the information yet!

$45.00 Quantity

Initial Consultation

First visit? We offer in-office, virtual, or hospital consults.

Please complete this form to the best of your ability.

$85.00 Quantity

In-Home Initial Consultation

First visit? We are happy to come to your home to support your lactation needs.

Please complete this form to the best of your ability.

$95.00 Quantity

Follow-Up Visit

For established patients only.

Please complete any updated information from your last visit.

$65.00 Quantity

In-Home Follow-Up Visit

For established patients only. We are happy to come to your home to support your lactation needs.

Please complete any updated information from your last visit.

$75.00 Quantity

Total

Requested Date of Service (*we will contact you to confirm your appointment)

Date

Parent/Guardian Full Name:

First NameLast Name

Parent's DOB:

Date

Partner/Support Person (optional):

First NameLast Name

Address:

Include city, state, and ZIP

Phone:

Format: (000) 000-0000.

Email:

example@example.com

Preferred Language:

How did you hear about us?

Primary Insurance:

Secondary Insurance:

We are not currently billing insurance. Payment is due at the time of service.

Name:

Relationship:

Phone:

Format: (000) 000-0000.

Pediatrician:

OB/GYN:

Rows	Time	Breast (L/R/Both)	Bottle (or)	Formula (od)	Pumped (oc)	Notes
1
2
3
4
5
6

Rows	Not at all	Several Days	More than half the days	Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Little interest or pleasure in doing things
4. Feeling down, depressed, or hopeless

Real Birth Knowledge, LLC Lactation Intake Form

Visit Type:

Payment Methods