Breastfeeding Intake Form
Thank you for scheduling an appointment with us. The goal of this consultation is to determine if there is a physical oral problem affecting your ability to breastfeed/feed your baby.
Today's Date:
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How were you referred to our office?
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Parent Information
Parent Name
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Parent Phone Number
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Parent Email
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Best Time To Contact You
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Address
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Infant Information
Patient Name (baby):
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Sex
D.O.B
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Birth Weight:
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Current Weight:
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Birth History:
Full Term:
Number of weeks:
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Birth Details
Physician's Name:
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