Request for Lactation Services
Our IBCLCs, Kim and Jenn, would love to assist you with your breastfeeding journey.  

By completing this form below, you are letting us know you would like to be contacted about scheduling a lactation consultation, either prenatally or postpartum.  

Our lactation team will contact you within two business days (Monday through Friday).  
Email *
Location Preference *
Mother's legal first and last name *
Mother's date of birth  *
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Baby's first name (if already born)
Baby's last name (if already born)
Baby's date of birth or estimated due date (if pregnant) *
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Baby's sex
Phone (xxx-xxx-xxxx) *
Email  *
Address (street, city, state, zip) *
Type of insurance  *
Is your policy an HMO or do you have Tricare? 

If the answer is yes, please be aware you will require an insurance referral and/or further information will be required for scheduling an appointment.  
 *
Insurance policy # *
Please note: 
When being seen for an appointment, you and your infant will both be patients with applicable copays/deductibles, unless otherwise specified at the time of booking.  
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Required
Support person's name
Tell us a little bit about how we can help.  *
How did you find out about us? *
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