Balanced Breastfeeding Appointment Request

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Please complete the form below to request an appointment.

If you have already had an appointment for this pregnancy and/or baby, do NOT fill out this form. Email info@balancedbreastfeeding.com to schedule.

First Name *

Last Name *

Email Address *

Phone Number *

Reason for appointment? *

Prenatal Visit

Postpartum Visit

When is your due date or when did you deliver? *

YYYY

Share more details about your need for the appointment here.

Have you had an appointment at Balanced Breastfeeding before? *

Yes, for a previous pregnancy/baby

No, I am a new client

When would you like an appointment?

**If you are pregnant, be sure to include SPECIFIC DATES & TIME OF DAY between 28 and 32 weeks. Appointments are one hour and in person at our office.**

Appointment hours are M-Th 9-3:30

I have reviewed insurance and fee for service pricing and understand I am responsible for the cost of the visit if not approved for insurance coverage through The Lactation Network PRIOR to my appointment day and time. The TLN form must be completed for approval. *

Yes, I have reviewed pricing and insurance information found at balancedbreastfeeding.com/consultations

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