Feeding/Lactation Intake & Consent Form

Will your appointment be in-office, virtual, or at home?

Other

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.)

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.

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)?

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

Other

Baby's Full Name

First NameMiddle NameLast Name

Baby's Date of Birth

MonthDayYear

Baby's Date of Birth

Date

Baby's Sex

Other

Baby's Birth Weight

Baby's Gestational Age at Birth (e.g. 40 weeks 3 days)

Location of Birth

Do you have multiples?

Baby B Full Name

First NameMiddle NameLast Name

Baby B Sex

Other

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

Date

Please select all that apply to Parent 1:

Parent 1 Pronouns

Other

Parent 1 Sex

Other

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)

Parent 1 Return to Work Date

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)

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

Date

Please select all that apply to Parent 2:

Parent 2 Pronouns

Other

Parent 2 Sex

Other

Parent 2 Phone Number

Area CodePhone Number

Parent 2 Work Status (check all that apply)

Parent 2 Return to Work Date

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:

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:

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?

Birth History - Did any of the following occur during the birth?

Breast/Chest feeding - check all that apply

Feeding Tools Used - check all that apply

Brand/Type of Bottle

Brand/Type of Pacifier

Infant Intake

Rows	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

Rows	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 - Do you have now, or have you had in the past, any of the following issues:

Rows	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

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:

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?

Pumping/milk expression:

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

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 - Do you have now, or have you had in the past, any of the following issues:

Rows	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

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:

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?

Pumping/milk expression:

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

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 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.

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.

Other

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):

Other

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

Date

Dropbox File Name - Hidden Field

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