Premier Lactation Services Contact Form
Please completely fill out your information and a message for our team. We will contact you as soon as possible after we have reviewed your submission. If you are already in contact with a consultant, indicate the PLS consultant you are working with.

If you are also uploading documents, use the Forms & Insurance link on the main page.

Email address *
Your Full Name *
Your answer
Phone Number *
Your answer
Address *
Your answer
City, State, Zip Code *
Your answer
Infant's Name *
Your answer
Infant's Birth Date *
Message For PLS *
Your answer
Consent Agreement *
I understand a lactation consultant is an allied health care provider along with my Pediatrician/PCP. Any changes from a physician's recommendation should be discussed with my physician. I am responsible for informing the lactation consultant of any changes or resolution of a breastfeeding problem. Resolution may take days or weeks, and may require a change from the original advice/care plan. I also understand if this is an email/phone consult, there is no fee-for-service charge, but donations are appreciated.
How Did You Hear About Us?
Your answer
Consultant Contact
Indicate the PLS consultant you are already working with (If Applicable)
Thank You and God Bless
Laura, Jennifer, Rachel, Sharon
Premier Lactation Services
Laura, Jennifer, Rachel, Sharon
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service