Live Virtual and In Person Lactation Consultations

Registration Options

per person-In Person Lactation Consult ($60.00)
per person- Live Virtual Lactation consult Consult ($40.00)
Follow-up Lactation Consult ($40.00)
Breast pump Flange Fitting ($25.00)

Mother's Birth Date/Age

Marital Status

Married
Single
Divorced
Widowed

Have you completed your COVID vaccination series greater than 14 days ago?

Have you tested positive for COVID-19 in the last 10 days?

If you answered yes, what was the date of your positive test?

Number of Pregnancies

Baby's Gender

Male
Female

How many weeks gestation at birth?

Most Recent Weight/Date

Latched in NICU

Baby is feeding via:

Breast
Pumped Breastmilk
Formula

Number of Feedings in 24 hours

Minutes per feeding-Breast?

Ounces per feeding - Bottle?

6 or more wet diapers per 24 hours?

3 Stools or more per 24 hours?

Ounces per pump Left side/Right side

Nipple Shield Use?/Size?

I need the most help during this consult with

In the past 7 days, I have been able to laugh and see the funny side of things

As much as I always could
Not quite so much now
Definitely not so much now
Not at all

In the past 7 days, I have looked forward with enjoyment to things

As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all

In the past 7 days, I have blamed myself unnecessarily when things went wrong

Yes, most of the time
Yes, some of the time
Not very often
No, never

In the past 7 days, I have been anxious or worried for no good reason

No, not at all
Hardly ever
Yes, sometimes
Yes, very often

In the past 7 days, I have felt scared or panicky for no very good reason

Yes, quite a lot
Yes, sometimes
No, not much
No, not at all

In the past 7 days, things have been getting on top of me

Yes, most of the time I haven't been able to cope at all
Yes, sometimes I haven't been coping as well as usual
No, most of the time I have coped quite well
No, I have been coping as well as ever

In the past 7 days, I have been so unhappy that I have had difficulty sleeping

Yes, most of the time
Yes, sometimes
Not very often
No, not at all

In the past 7 days, I have felt sad or miserable

Yes, most of the time
Yes, some of the time
Not very often
No, never

In the past 7 days, I have been so unhappy that I have been crying

Yes, most of the time
Yes, quite often
Only occasionally
No, never

In the past 7 days, The thought of harming myself or my baby has occurred to me

Yes, quite often
Sometimes
Hardly Ever
Never

Lactation Services Consent

CONSENT FOR TREATMENT
I hereby give consent for a Lactation Consultant to observe me
nursing my child, to examine and/or touch my breasts should this
become necessary during the course of breastfeeding assistance.
I understand that all medical care is to be provided by my
physician.
The Lactation Consultant has my permission to contact my
physician(s) with her findings and/or any pertinent information
regarding my child’s care or mine.

I, the undersigned, agree to the terms above.

HIPPA

I have read and agree to the terms above.

Sessions*

July 26, 2024 [Sold Out]
9:30am-10:30am
July 26, 2024 [Sold Out]
1:30pm-2:30pm
July 29, 2024 [1 remaining]
9:30am-10:30am
Attend This Session
July 29, 2024 [1 remaining]
1:30pm-2:30pm
Attend This Session
July 30, 2024 [1 remaining]
9:30am-10:30am
Attend This Session
July 31, 2024 [1 remaining]
9:30am-10:30am
Attend This Session
August 1, 2024 [1 remaining]
9:30am-10:30am
Attend This Session
August 1, 2024 [1 remaining]
1:30pm-2:30pm
Attend This Session
August 2, 2024 [Sold Out]
9:30am-10:30am
August 2, 2024 [Sold Out]
1:30pm-2:30pm

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Sessions*

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