Intake Form
Please fill out this form when booking your consultation, by filling this form out prior to our appointment saves us time to focus just on my assessment and breastfeeding. This form is HIPAA compliant.
Email address *
Legal Name & Date of Birth *
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Home address: Street *
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Home Address: City *
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Home address: Zip code *
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Home address: State *
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Phone number *
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Client's Identifying Pronoun
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Infant's Name *
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Infant's date of birth *
MM
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DD
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YYYY
Reason for visit: *
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Aetna Plan
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Insurer's Name, DOB, and address if different from Patient's.
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Aetna Insurance ID # & Group ID #
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Infants location of birth (name of hospital/home) *
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Infant's Gestational Age at birth ie 36, 38, 41 weeks *
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Baby's birth weight *
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Infant's current weight + DATE *
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Feeding problems *
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Pediatrician name and Practice *Please list a Doctor's name so that I don't have to go in search when faxing your report, saves me time. Thank you. *
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Pediatrician Address *
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OB/Midwife name and Practice *
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OB/Midwife Address *
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Medical diagnosis I should know about? *
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Medications/ herbs taken during pregnancy/postpartum
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Breast surgery? If so explain...
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Breast development normal? *
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Fibrocystic breast/ Dense Breast tissue? *
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Breastfeeding history *
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Birth Type *
Birth complications? Trauma? *
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Personal trauma history? *
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How many pregnancies?
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How many living children?
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How many miscarriages? *
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Struggle with conceiving? If yes explain...
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History of Depression or Anxiety? Taking medication? *
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Infant medical complications? *
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NICU stay? *
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Age of baby when feeding issues occurred?
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Using a breast pump, other supplies?
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Supplementing formula or breastmilk? Explain.
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In past 24 hours how many oz supplemented? *
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How many times have you breastfed in the last 24 hours?
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How long is baby content between feedings?
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In last 24 hours How many stools
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In last 24 hours how many pee diapers *
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Nipple pain?
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Describe pain: irritating, rubbing, tingling; explain
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Describe nipple shape after feeding; elongated, creased, ridged, pinched
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Is there nipple damage?
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Breast pain? Explain
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Is there anything else you want me to know before our appointment?
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Client Signature & Date: *
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We require a credit card number on file to hold your appointment. This card will be charged in the event that you miss an appointment. We will also charge your card for any amounts your insurance plan does not cover--including, but not limited to: copay, coinsurance, or deductible.We will notify you before processing any charges related to insurance coverage.
Cardholder Name (as shown on card): *
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Card Number: *
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Expiration Date (mm/yy): *
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CVV number (last 3 digits on back of card) *
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Cardholder ZIP Code (from credit card billing address): *
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Credit card type: *
Other Credit card:
I authorize Riverside Lactation LLC to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account, included missed appointment fees. Please Sign & Date below: *
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Can I add your email to our email list? *
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