Feeding/Lactation Intake & Consent Form

Initial Intake: Infant Feeding & Lactation
Will your appointment be in-office, virtual, or at home?*

OfficeVirtualHomeOther
TRAVEL FEE: I understand that if I am outside our service area (10 miles radius from 97206), there will be a travel fee of $30 (which includes 10 miles beyond radius. For areas further than that, please ask office directly.)*

I understand
MASK REQUIREMENT: I understand that for all in-person appointments (both in-home and in-office), masks be worn by all people over the age of 2. Masks must be properly fitted and cover both the nose and mouth for the duration of the appointment.*

I understand
COVID SCREENING: In the past 10 days, have you or anyone in your household experienced or been in close contact with someone who has ANY of the following symptoms: fever, chills, coughing, fatigue (not related to having a newborn), sneezing, sudden loss of smell or taste, runny or stuffy nose, congestion, headaches, shortness of breath, difficulty breathing, sore throat, nausea, vomiting, diarrhea, or body aches and pains (not on your breasts/chest and not related to childbirth)?*

YesNo
VACCINES: Are the adults coming to the appointment fully vaccinated for COVID-19?*

YesNoOther
Basic Information
Baby's Full Name*

First NameMiddle NameLast Name
Baby's Date of Birth*

MonthDayYear
Baby's Date of Birth*

MonthDayYear
Date
Baby's Sex*

FemaleMaleOther
Baby's Birth Weight*
Baby's Gestational Age at Birth (e.g. 40 weeks 3 days)*
Location of Birth*
Do you have multiples?

Yes, twinsYes, triplets or moreNo
Baby B Full Name

First NameMiddle NameLast Name
Baby B Sex

FemaleMaleOther
Baby B Birth Weight
For triplets or more, please list each baby's full name, birth weight and sex:
Pediatric Primary Care Provider (PCP)*
PCP Phone Number

Area CodePhone Number
PCP Fax Number

Area CodePhone Number
Parent 1 Name*

First NameLast Name
Parent 1 Date of Birth*

MonthDayYear
Date
Please select all that apply to Parent 1:*

I gestated the babyI am breast/chest feeding the babyI am bottle feeding or using other feeding toolsNone of the aboveOther
Parent 1 Pronouns

She/HerHe/HimThey/ThemOther
Parent 1 Sex

FemaleMaleOther
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
Parent 1 Phone Number*

Area CodePhone Number
Parent 1 Work Status (check all that apply)

Currently workingStay at home parentDisabled fom workOn parental leaveWill return to part time workWill return to full time workOther
Parent 1 Return to Work Date

MonthDayYear
Date
Parent 1 Occupation
Parent 1 Employer
Parent 1 Parental Primary Care Provider (PCP)
Parent 1 PCP Phone Number

Area CodePhone Number
Parent 1 PCP Fax Number

Area CodePhone Number
Parent 1 OBGYN/Midwife
Parent 1 OBGYN/Midwife Phone Number

Area CodePhone Number
Parent 1 OBGYN/Midwife Fax Number

Area CodePhone Number
I was referred to this practice by:*
Relationship Status (check all that apply)

SingleMarriedDivorcedWidowedSeparatedDomestic PartnerPoly FamilyOther
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Do you have any religious or spiritual practices you'd like us to know about?
Parent 2 Name

First NameLast Name
Parent 2 Date of Birth

MonthDayYear
Date
Please select all that apply to Parent 2:

I gestated the babyI am breast/chest feeding the babyI am bottle feeding or using other feeding toolsNone of the aboveOther
Parent 2 Pronouns

She/HerHe/HimThey/ThemOther
Parent 2 Sex

FemaleMaleOther
Parent 2 Phone Number

Area CodePhone Number
Parent 2 Work Status (check all that apply)

Currently workingStay at home parentDisabled from workOn parental leaveWill return to part time workWill return to full time work
Parent 2 Return to Work Date

MonthDayYear
Date
Parent 2 Occupation
Parent 2 Employer
Parental Primary Care Provider (PCP)
Parent 2 PCP Phone Number

Area CodePhone Number
Parent 2 PCP Fax Number

Area CodePhone Number
Parent 2 OBGYN/Midwife
Parent 2 OBGYN/Midwife Phone Number

Area CodePhone Number
Parent 2 OBGYN/Midwife Fax Number

Area CodePhone Number
Please list names and dates of birth for any other partners/parents:
Baby's Health History
What feeding, lactation or health problems concern you? What are your goals for this consultation?*
Baby's Health - List any issues, past or present, that have affected your baby:*

No issues to reportblood sugar issuesjaundicemeconium aspirationrespiratory issuesmedical/congential condtitionknown tongue or lip tieknown cleft palate or lipdigestive issues (reflux, spit up, stool concerns, etc)yeast/thrushfussy baby/colicky babyTorticollis/PlagiocephalyOther
If a tongue and/or lip tie was released, please list the date of the procedure and the provider that performed the surgery:
Baby's Health - Are any of the following part of the baby's family history?*

genetic issuesankyloglossia (tongue tie)allergiesthyroid disordersautoimmune issuesalcoholismnone of the aboveOther
Birth History - Did any of the following occur during the birth?*

No issues to reportinduction (rupture of membranes, pitocin, etc)pain meds (epidural, narcotics, etc)blood pressure concernsfever/infectiongroup B strep positivehemorrhage/excessive bleedingepisiotomy/tearingpushing stage longer than 2 hoursbreech position of babyvaginal deliveryvacuum or forceps assistedcesarean delivery (planned or emergency)retained placenta requiring ultrasound and/or removalantibiotics neededOther
Breast/Chest feeding - check all that apply*

Exclusively breastfedNeeded supplementation early on but not nowSome breastfeeding but not exclusiveUses a nipple shieldBaby will latch but is inefficient, sleepy or causes painBaby not latching/breastfeeding at all
Feeding Tools Used - check all that apply*

BottleFinger feedingAt breast/chest supplementer (SNS, tube, etc)CupPacifierSpoonNG tubeG tube
Brand/Type of Bottle
Brand/Type of Pacifier

Infant Intake*

	Times/day	Quantity (oz/ml)
Feeding directly at breast/chest
Parent's own expressed/pumped milk
Donor milk
Formula
Solid foods
Bottle/supplemental feeding device

Brand/Type of formula

Infant Output*

	Number per day	Consistency/Notes
Wet Diapers
Bowel Movements
Spit Up

List any medications, vitamins, or herbs the baby gets:
Any other notes you want to share about baby's feeding or digestion?
What is your baby's sleep like? What is the longest sleep stretch your baby gets on average?
Parental Health History - Parent 1

Please list your allergies (to food, medicine, or environmental)
Please tell us about any hormonal/endocrine issues (such as pregnancy loss, PCOS, thyroid disorders, fertility issues/trouble conceiving, assisted conception)
Breast/Chest Health - Please list any breast/chest-related issues that apply to you:

implantsreduction surgerybreast/nipple biopsynipple piercingsherpes on the nipplenone or minimal breast changes in pregnancy/postpartumhistory of chest tubemastitissevere engorgmentcracked/bleeding nipplesmilk supply concernssore nipplesthrush/yeast of the nippleno breast/chest-related concerns to reportOther
Please list any topical nipple treatments you may be using now. Example: Nipple cream, lanolin, silverettes, APNO, etc.
For any breast or nipple procedures or surgeries, please list the year and any related notes:
Please list any medication, herbs, vitamins , supplements, and/or birth control you are taking? Also list dosage if known.
What is your current form or future method of birth control? When did or will you start it?
Number of pregnancies you have had:
Number of live births you have had:
Number of infant losses (miscarriage, stillbirth, or elective termination) you have had:
Pregnancy History - Did you experience any of the following during your most recent pregnancy?

preterm laborblood pressure issuesblood sugar issuessevere nauseainfection/feverassisted conceptionno concerns to reportcholestasisPUPPPOther

Please list names, dates of birth of any other children. If you breast/chest fed them, did you have any issues? If yes, please explain:
Tell me about your mood. Are you feeling anxious, sad, depressed, angry, overwhelmed, etc?
Do you have experience with negative touch you want the IBCLC to know about?
Parental Health History - Parent 2

Please list your allergies (to food, medicine, or environmental)
Please tell us about any hormonal/endocrine issues (such as pregnancy loss, PCOS, thyroid disorders, fertility issues/trouble conceiving, assisted conception)
Breast/Chest Health - Please list any breast/chest-related issues that apply to you:

implantsreduction surgerybreast/nipple biopsynipple piercingsherpes on the nipplenone or minimal breast changes in pregnancy/postpartumhistory of chest tubemastitissevere engorgmentcracked/bleeding nipplesmilk supply concernssore nipplesthrush/yeast of the nippleno breast/chest-related concerns to reportOther
Are you using anything topical on your nipples right now? If yes, what?
For any breast or nipple procedures/surgeries, please list the year and any related notes:
Are you taking any medication, herbs, vitamins , or supplements? List medication and dosage per day:
What is your current form or future method of birth control? When did or will you start it?
Number of pregnancies you have had:
Number of live births you have had:
Number of infant losses (miscarriage or elective termination) you have had:
Pregnancy History - Did you experience any of the following during your most recent pregnancy?

preterm laborblood pressure issuesblood sugar issuessevere nauseainfection/feverassisted conceptionPUPPPcholestasisno concerns to reportOther

Please list names, dates of birth of any other children. If you breastfed them, did you have any issues? If yes, please explain:
Tell me about your mood. Are you feeling anxious, sad, depressed, angry, overwhelmed, etc?
Do you have experience with negative touch you want the IBCLC to know about?
Is there anything else you want the lactation consultant to know?
Consent and Release of Information
Consent Agreement to read and sign before the consultation:

*I understand the following: The lactation consultant is an allied health care provider and responsible for evaluating and recommending a care path to resolve or improve feeding issues. A lactation visit includes a detailed history of parent/infant, an assessment of parent/infant anatomy, observation of a feeding for evaluation of technique and effectiveness of feeding, and recommendations for management to improve and/or resolve feeding related issues. All clients are provided with a written and/or oral care path to improve feeding concerns. The client and the lactation consultant each have responsibilities in this path. Resolution of a feeding problem often takes several days or weeks and may require a change in the original recommended care path at some point.

*I understand that I am responsible for informing the lactation consultant of changes I feel are necessary in the care path at the time of the visit or during the course of follow-up communications. Phone contact during the time following the lactation visit is crucial and considered an extension of your visit. You will be given a phone number to call to report progress or to communicate continued problems or concerns. I understand it is my responsibility to contact the lactation consultant with progress reports, questions or concerns.

*I understand any change from my physician’s recommendations should be discussed with the physician.

*I understand a partial or follow-up visit is sometimes necessary. I understand that feeding supplies and/or pumps may be recommended as effective management of specific situations. Only effective equipment will be recommended. If a client chooses to utilize any equipment, supplies or nutritional supplements risks and benefits will be discussed but the client is responsible for choosing whether or not to use these items and for any associated outcomes.

*I hereby authorize the lactation consultant to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers, referring physician, referring lay feeding counselor, and/or our insurance company upon request. I understand the lactation consultant may contact my physician or my child’s physician if the lactation consultant feels it is necessary to consult with the physician.

*I have received a copy of this provider’s HIPAA Privacy Practices or viewed them online HERE

*I understand this practice accepts only fee for service at time of service. It is my responsibility to pursue reimbursement for lactation services from my insurance company. This practice does no billing for insurance reimbursement and is not a provider on any insurance plan. Reimbursement is not guaranteed, but filing is suggested.
Luna Lactation's preferred method of communication is via the Patient Portal, which is HIPAA compliant and secure. I give permission for the lactation consultant to communicate with me via phone, email and/or text message in regards to my case following our visit (which are sometimes considered unsecured forms of communication). Luna Lactation adheres to HIPAA privacy practices but realizes some patients may choose unsecured text and email contact for convenience at their own discretion. Secure messaging through our patient portal is preferred.*

YesNo
I give permission for information, photos and/or videos of my lactation visit to be used for professional, clinical research, education and/or articles. I understand all identifying factors will be removed.*

YesNoOther
I consent to an intern being present during my consultation. We occasionally have interns observing consultations as part of their own education. Any interns we have in office, as well as all staff, are fully vaccinated and comply with HIPAA):*

YesNoOther
Signature - I have read the above consent and release information and agree to the terms. (Typing your name below qualifies as a digital signature)*
Date signed*

MonthDayYear
Date Signed*

MonthDayYear
Date
Dropbox File Name - Hidden Field
Should be Empty:

	IN THE PRESENT	IN THE PAST
Hormonal/endocrine issues
Anemia
Blood pressure issues
Liver/gallbladder issues
Yeast infections
Abuse
Asthma
Eating disorders
Kidney/bladder issues
Autoimmune condition
Cardiac/respiratory issues
Digestive issues
Surgery
Herpes simplex virus
Vegan diet
Vegetarian diet
Alcohol use
Tobacco use
Drug use
Mood concerns (depression, anxiety, etc)
Allergies
Visible/invisible disabilities
No conditions to report

	Times/day	Output/yield	Brand used	Flange size
Electric pump
Manual pump
Hand expressing

	IN THE PRESENT	IN THE PAST
Hormonal/endocrine issues
Anemia
Blood pressure issues
Liver/gallbladder issues
Yeast infections
Abuse
Asthma
Eating disorders
Kidney/bladder issues
Autoimmune condition
Cardiac/respiratory issues
Digestive issues
Surgery
Herpes Simplex Virus
Vegan diet
Vegetarian diet
Alcohol use
Tobacco use
Drug use
Mood concerns (depression, anxiety, etc)
Allergies
Visible/invisible disabilities
No conditions to report

	Times/day	Output/yield	Brand used
Electric pump
Manual pump
Hand expressing

Initial Intake: Infant Feeding & Lactation

Basic Information

Baby's Health History

Parental Health History - Parent 1

Parental Health History - Parent 2

Consent and Release of Information