Milky Way Lactation Services - Intake Form and Consent to Receive Services
Please complete this intake form to help us understand your needs and provide personalized breastfeeding support.
Parent Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Baby's Full Name
*
First Name
Last Name
Baby's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How was your baby delivered?
Vaginal
Cesarean (C-section)
Assisted (forceps/vacuum)
Other
How much did baby weigh at birth?
Please describe any latch or feeding concerns you have.
*
How would you rate your current breastfeeding experience?
*
1
2
3
4
5
Have you previously received breastfeeding support?
*
Yes
No
How many times per day is baby feeding at the breast?
How many wet diapers per day is baby having?
How many bowel movements per day is baby having?
Please list any medications you or baby are currently taking.
What are your breastfeeding goals?
Do you or your baby have any medical conditions we should be aware of?
Preferred appointment times (please select all that apply):
Morning (8am - 12pm)
Afternoon (12pm - 4pm)
Evening (4pm - 8pm)
Other
Is there anything else you would like us to know?
Signature (please sign below to confirm your consent and understanding)
*
Submit Intake Form
Submit Intake Form
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