Intake Form
Email address *
Lactating Parent's Name *
Your answer
Parent's Date of Birth: *
MM
/
DD
/
YYYY
Address: *
Your answer
Cell Phone: *
Your answer
Occupation and Return to Work Date: *
Your answer
Health Insurance and Plan type (HMO or PPO)?
Your answer
If you have a PPO plan with Anthem BCBS, UHC, or Cigna, please complete this online form for possible insurance coverage: https://info.ashlandhealthrx.com/lactation-consultant-request/
Partner's Name:
Your answer
Contact information in case of emergency: *
Your answer
OB/GYN or Midwife (first and last name) and Fax Number: *
Your answer
Pediatrician or Family Physician (first and last name) and Fax Number: *
Your answer
Referred by: *
Preferred method of contact *
Required
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