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Intake, Consent & Appointment Request

Parent Information

Birthday
Ethnicity, Race, Gender (select all that apply)
Maternal (Select all that apply)
Lactation and Feeding (Select all that currently apply)

Pump type/brand:

Output per session: ___oz

Flange size:___mm

Pumping Discomfort?

Infant Information

Infant's Birthdate
Feeding Information (select all that currently apply)

Gestational Age at Birth:

☐ Male ☐ Female ☐

Birth Weight: __(lbs/oz)

2-Week Weight: _______ Date: __________

Current Weight: ________ Date: __________

Delivery Type: ☐ Vaginal

☐ Cesarean ☐ VBAC Birth

Facility / Hospital:

NICU Stay?

Tongue/Lip Tie?

Times breastfed in last 24h:

Duration (avg minutes per feed):

Baby content/sleep between feeds:

Bottles in last 24h:

Longest day interval (hrs):

Night interval (hrs):

Wet diapers (24h):

Soiled diapers (24h):

Over the last 2 weeks, how often have you been bothered by the following problem? Little interest or pleasure in doing things.
Over the last 2 weeks, how often have you been bothered by the following problem? Feeling down, depressed or hopeless.

Please share three dates and times that work best for you! We’ll do our best to match your availability. Once your appointment is booked, you’ll receive a text confirmation from our office.

Time
時間
時間分鐘
Time
時間
時間分鐘
Time
時間
時間分鐘
Please choose the lactation service that best fits your current needs: (Appointment types are explained on the previous page)

Consent to Lactation Care I understand that lactation consultants at WNY Latch Lab provide evidence-based lactation assessment, education, and support. I consent to an examination of the breasts/chest, observation of feeding, and oral assessment of my infant as part of the care process. I understand that IBCLCs do not diagnose or prescribe medication. I agree to contact my healthcare provider for medical concerns. I authorize WNY Latch Lab to communicate with my healthcare providers as needed for coordinated care. If I listed my OB and/or pediatrician. I consent to sharing relevant lactation information with those providers. I consent to follow-up contact by text, phone, or email, and understand telehealth visits may be used when appropriate.

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Date

Phone/Text 585-888-1063

Email wnylatchlab@gmail.com

Facebook @WNYLatchLab



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