Appointment Request Form

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Thank you for your interest in a lactation consultation. To schedule an appointment with us, please fill out the form below. We will reach out to you with scheduling options and more details as soon as possible. We look forward to serving your family!

Email *

First and Last Name *

What town do you live in? *

What is the best number to contact you? *

What feeding problems are you having?

Painful latch

Low supply concerns

Slow weight gain in baby

Tongue and lip tie concerns

Latching difficulty

Bottle refusal

Breast refusal

Post tongue tie release support

Other:

What insurance plan do you have? *

BCBS or Anthem Commercial Plan

Tenncare (Bluecare, United Healthcare Community Plan, or Wellpoint)

Aetna

Cigna

BCBS Federal Plan

Self Pay

United Healthcare Commercial

UMR

Other:

Required

How urgent is your request? *

Urgent (need to be seen within 3 days)

Non-urgent (within 7-10 days)

Planning Ahead (prenatal breastfeeding class)

Other:

Who referred you?

Send me a copy of my responses.

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