REGISTRATION FORM - Lactation Intake & Payment Form

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TYPE OF VISIT: VIRTUAL or IN-PERSON (Select one):(Required)

$200.00 - 1 HOUR - VIRTUAL BF VISIT

$400.00 - 2 HOUR - IN-PERSON BF VISIT

TYPE OF VISIT:

This is my First Visit

This is a follow-up Visit

WHAT TYPE OF VISIT SHOULD I CHOOSE?
(Click Below to see Description)
VIRTUAL VISIT OR IN-PERSON VISIT

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IMPORTANT INFORMATION: SCHEDULING AN APPOINTMENT

CAN I CONFIRM LACTATION SERVICES BEFORE THE BIRTH OF THE BABY? Yes. Complete as much of this Intake Form as possible. You may not be able to complete all the sections until the baby has arrived, but the portions that include your contact information and payment information and some general information about you and your breastfeeding goals can be completed. When your baby has been born, please contact us so that we can schedule your visit.

MY BABY IS HERE. I NEED TO SCHEDULE AN APPOINTMENT: BEFORE COMPLETING FORM CONTACT US FOR AVAILABLE APPOINTMENT DATES. REQUEST AN APPOINTMENT HERE.

🖥️ Virtual Visits: Virtual Visits can be scheduled within 72 hours of requesting an appointment.
🤱In-person Visits: In-person visits can be within 3 - 7 business days of requesting an appointment.
🚨I NEED IN-PERSON HELP ASAP! (IMMEDIATE VISIT): Need help right away? Please contact us HERE or at (954) 433-CARE (2273) to request an immediate visit. There is an additional $100.00 fee for visits scheduled within 48 business hours.
🚗 PARKING AT YOUR LOCATION: VISIT RATE DOES NOT INCLUDE PARKING FEES. You are responsible to cover any fees required to park at your residence.

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Your Full Name (First/Last):(Required)

First Last

Your Partner/Spouse's Full Name (First/Last): (if applicable)

First Last

Preferred Phone Number:(Required)

I consent to receiving text messages so MC or the Lactation Specialist can communication with me:(Required)

Yes

NO marketing material will be sent to you. Text is used only as a form of communication to answer your questions or follow up with you regarding services.

Preferred Email:(Required)

FOR IN-PERSON VISIT - Address where the Visit will take Place:

Street Address City ZIP / Postal Code

If you have selected to have a VIRTUAL VISIT - Leave this section empty

How did you hear about us? If you were referred to us, please tell us who referred you (first & last name):(Required)

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BABY'S BASIC INFORMATION:

HAS THE BABY BEEN BORN?(Required)

YES

Baby's Date of Birth: (Month / Date / Year)

Baby's Estimated Due Date: (Month / Date / Year)

Baby's Name:

Baby's weight at birth?

Last Pediatric Appointment (Date):

Current weight/most recent weight:

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REASONS YOU NEED ASSISTANCE:

REASON FOR VISIT: Please describe your concerns and or breastfeeding goals and why you feel you need assistance:(Required)

Provide as many details as you can that will the Specialist know what areas to target when working with you and your baby.

If you have received breastfeeding help from another lactation specialist or healthcare provider, please share who helped you and what suggestions you were given, what helped and what didn’t? Is there anything you’ve researched/tried on your own to troubleshoot solutions for your breastfeeding concerns? What helped and what didn't?

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I WOULD LIKE TO PROVIDE COMPREHENSIVE DETAILS OF MY BREASTFEEDING EXPERIENCE

If you select "Yes" Below, Complete the Rest of the Form then Payment Info to Confirm your Appointment

If you select "No", Complete Payment Information to Confirm your Appointment

PLEASE KEEP IN MIND THE MORE INFORMATION YOU PROVIDE IN ADVANCE,
THE BETTER YOUR MC LACTATION SPECIALIST IS ABLE TO HELP YOU BY OFFERING TOOLS, STRATEGIES AND INFORMATION DURING YOUR VISIT.

ADD MORE DETAILS?(Required)

Yes - I prefer to add details so the Specialist has more info about my situation.

No - I prefer to discuss details with the Specialist during my visit.

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OB or Midwives Name (First/Last):(Required)

Location of Birth: (Hospital Name, Birth Center Name or Home)(Required)

(Hospital or Facility Name, Birth Center Name. If your baby was born at home, please write "home birth".)

Pediatrician's Name (First/Last):(Required)

PAIN & CURRENT CHALLENGES

Are you experiencing Nipple Pain?(Required)

Yes

Form Completed Prenatally: I haven't started nursing/pumping.

Are you experiencing Nipple Cracking and or Bleeding?(Required)

Yes

Form Completed Prenatally: I haven't started nursing/pumping.

Are you currently experiencing "Engorgement"?(Required)

Yes

I'm not sure if I have engorgement

Form Completed Prenatally: I haven't started nursing/pumping.

The breast feel very hard, heavy and or "stretched". Breast may feel "lumpy" and "stiff". Breast may feel warm and tender to the touch and/or feel like it's "throbbing". The breast may look and feel swollen. Swelling may extend up towards the armpit. The areola wil feel hard, may increase in diameter and become flat and taut. You may also have a low-grade fever (99.6°F to 100.3°F).

How long have you been experiencing "Engorgement"?(Required)

Less than 72 hours

More than 72 hours

I'm not sure.

I haven't had any engorgement problems.

Form Completed Prenatally: I haven't started nursing/pumping.

MILK SUPPLY CONCERNS & CHALLENGES

Are you currently experiencing "Low Milk Supply" or have concerns with your breastmilk production?(Required)

Yes

I'm not sure.

Form Completed Prenatally: I haven't started nursing/pumping.

Have you tried any "home remedies" or treatments to treat "Low Milk Supply"? If you are taking herbs, edible products like "lactation cookies" and/or supplements to "increase" your milk production/supply, please list them by name.

Yes

Form Completed Prenatally: I haven't started nursing/pumping.

Include the names of any products or treatments you've used or are using including the name of any supplements, herbs, edibles, etc. that you have tried or have purchased to try.

BREASTFEEDING CONCERNS & CHALLENGES FOR MOM:

Please select any other challenges YOU are experiencing or are concerned about: (select all that apply)(Required)
I can latch the baby on myself but with difficulty.
I have NO Milk Production (producing no breastmilk at all).
I produce much more milk from one breast and barely any milk from the other (there's a significant difference).
I am producing so much milk from both breasts it's causing pain/problems.
I currently have a Plugged Duct.
I do not have a Plugged Duct now but I did recently (within 7 days).
I do not have any of the challenges above.
Form Completed Prenatally: I haven't started nursing/pumping.

MOM Nursing Challenges Continued... (select all that apply)(Required)
I currently have Mastitis.
I do not have Mastitis now but I did recently (within 7 days).
I am experiencing severe itchiness or burning sensations around Nipple & Areola.
I feel Frustration and/or Disappointment with Breastfeeding.
I do not have any of the challenges above.
Form Completed Prenatally: I haven't started nursing/pumping.

BREASTFEEDING CONCERNS & CHALLENGES FOR BABY:

Please select any challenges THE BABY is experiencing or challenges you are concerned about: (select all that apply)(Required)
Difficulty Staying Latched on.
Tries but seems unable to latch.
Shallow latch.
Slipping off nipple frequently.
Biting / Clamping down hard on nipple.
Making "clicking" sounds while feeding.
Excessive weight loss.
Slow weight gain.
Short Feedings (nursing for LESS than 30 total minutes).
Excessive Long feedings (nursing for MORE than 30 total minutes).
Frequent feedings (Nursing "too much").
Infrequent feedings (Not nursing "enough").
Sleepy / Lethargic and/or Falling asleep during feeding.
Infrequent stools (not pooping the minimum recommended amount).
Too frequent stools (pooping much more than normal - concerned that baby has diarrhea).
The baby does not have any of the challenges above.
Form Completed Prenatally: I haven't started nursing/pumping.

BABY Nursing Challenges Continued... (select all that apply)(Required)
Mucus or "frothy" stools.
Gagging during latching and/or nursing.
Choking during nursing.
Fussing / crying during nursing.
Frequent restlessness during nursing.
Seems unsatisfied after nursing.
Hiccups frequently after nursing.
Gassiness/Spit up frequently after nursing.
Grunting during nursing.
Diaper rash (Minor or Severe).
White coating and/or white "pearls" in mouth/tongue.
Prefers one breast over the other.
Outright refuses or seems "unwilling" to nurse at all.
Cranial/head injury from birth.
The baby does not have any of the challenges above.
Form Completed Prenatally: I haven't started nursing/pumping.

My baby was evaluated for a Tongue and Lip Tie:(Required)

Yes

No

I'm not sure / I was never told

Form Completed Prenatally: Baby has not yet arrived.

The person who evaluated my baby was: (select all that apply)(Required)
The Pediatrician at the hospital.
My Baby's Pediatrician.
The Nurse at the hospital.
A Nurse at my Pediatrician's Office.
A Lactation Consultant at the Hospital.
A Lactation Consultant I hired privately.
A Pediatric ENT (Ear, Nose & Throat Doctor).
I've never had the baby evaluated but I suspect the baby has a tongue and/or lip tie.
I'm not sure / I was never told.
Form Completed Prenatally: Baby has not yet arrived.

If your baby was evaluated and a Frenectomy performed, please provide the date of the procedure, what post-procedure therapy you were instructed to perform (tongue & lip massage, craniosacral therapy, etc.), and if there is a follow up visit (list the date)

CURRENT HEALTH & HISTORY (MOM):

BREAST PROCEDURES: (select all that apply)(Required)
I've had one or more breast surgeries or medical procedures on my breasts.
I have breast implants.
I had breast implants but they were removed.
I had a breast reduction.
I had a breast lift.
I had a biopsy to one or both my breasts in the past.
I do not have any of these.

Breast Procedures Continued... (select all that apply)(Required)
I've had a lumpectomy.
I had or have had a nipple piercing.
I have had a breast injury in the past.
I currently have breast cancer.
I was diagnosed with breast cancer but I am in remission.
I had a Mastectomy on one or both breasts
I do not have any of these.

MEDICATIONS/SUPPLEMENTS (MOM): Are you taking any of the following:(Required)
Vitamins
Iron Supplements
Probiotic
Antibiotic
Stool Softener/Laxative
I am not taking anything listed here.

Medications/Supplements (Mom) Continued...(Required)
Placenta Pills, Tinctures or Raw placenta
Depression/Anxiety meds
Pain Medications (Over the counter)
Pain Medications (Prescribed by my doctor)
I am not taking anything listed here.

CURRENT HEALTH & HISTORY (BABY):

Does your baby have any Health Challenges? If so, please descibe. If none, write "None"(Required)

URINE (PEE) OUTPUT: How many wet diapers has the baby had in the last 24 hours?(Required)

4 heavy, wet, pale yellow diapers or more.

4 wet, yellow diapers or more but they are not "heavy".

Less than 4 heavy, wet diapers

I don't think the baby has peed in 24 hours.

Form Completed Prenatally: The baby has not yet arrived.

BOWEL MOVEMENTS (POOP): How many dirty diapers has the baby had in the last 24 hours?(Required)

4 dirty diapers or more with bright, mustard yellow and "seedy" looking poop.

4 dirty diapers but not all are bright, mustard yellow and "seedy" looking poop.

Less than 4 dirty diapers.

The baby has not pooped in 24 hours.

Form Completed Prenatally: The baby has not yet arrived.

FORMULA SUPPLEMENT:

FORMULA: Do you offer formula to your baby?(Required)

Yes - After EVERY nursing session

Yes - After SOME nursing sessions

No - I do not offer formula.

Form Completed Prenatally: Baby has not yet arrived.

FORMULA: What Brand of Formula are you using and how many ounces per bottle?

BREAST PUMP INFORMATION:

PUMPING: Are you pumping?(Required)

I am exclusively pumping for every feeding.

I am pumping to supplement with breastmilk for some feedings.

I have pumped as needed (infrequently or sporadically).

No, I have not pumped at all and do not plan to.

No, I have not pumped at all but would like to start.

Form Completed Prenatally: I haven't started nursing/pumping.

PUMPING: Where you "sized" for the breast shield/flange you are currently using?(Required)

Yes - I did it myself and I'm confident it's correct.

Yes - I did it myself but I'm not sure it's correct.

Yes - A professional did it (Lactation Consultant/Specialist) and I'm confident it's correct.

Yes - A professional did it (Lactation Consultant/Specialist) but I'm not sure it's correct.

No - I've heard of it but never did it.

No - I've never heard of this / I don't know what this means

I am not pumping at all.

Form Completed Prenatally: I haven't started nursing/pumping.

FINAL THOUGHTS or CONCERNS:

Is there anything else about you, your partner, your baby or your goals/wishes for breastfeeding and or pumping that have not been asked in this Questionnaire that you feel is important for us to know?

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CONSENT & AUTHORIZATION

CONSENT AUTHORIZATION:(Required)
I Agree & Consent to the following:
I give my consent for an MC Lactation Specialist to work with me and my baby for my specified breastfeeding challenge/concern.

I understand that a visit with an MC Lactation Specialist may involve: viewing and touching of my breasts and/or nipples for the purpose of assessment and inspection, observation of my latch techniques and will offer advice and suggestions to correct/enhance the latch and/or positioning of my baby.

I understand that the MC Lactation Specialist may insert a clean, gloved finger into my baby’s mouth to check for normal suckling strength and/or abnormalities.

I understand that the MC Lactation Specialist may also observe my baby’s diaper changes and view any diaper and feeding logs I have.

I understand that my visit may include the inspection of equipment such as my breast pump, pump accessories and or supplies and she may recommend other equipment or supplies to assist with my breastfeeding.

I understand that an MC Lactation Specialist will not perform any medical procedures, she will not provide a medical diagnosis, and she will not go against any recommendations my healthcare provider (including my baby's Pediatrician and my own medical doctor) has made.

I understand that an MC Lactation Specialist is trained to identify areas that can potentially create challenges with breastfeeding, my milk production, and my baby's growth and development and shares this information with me so that I can connect with the appropriate healthcare provider if the issues she has identified require a medical professional's evaluation.

I understand that an MC Lactation Specialist will assist me by creating a detailed list of questions and concerns I should present to my provider or my baby's Pediatrician for further clarification.

I understand that an MC Lactation Specialist will not offer “medical treatments” by prescribing or recommending medications (prescription or over-the-counter) but she can provide evidence-based information on various treatments, including medications if necessary, so that I can discuss treatment options with my provider or Pediatrician.

I understand and agree to inform my healthcare provider and/or Pediatrician about any supplements (galactagogues) that are commonly used to “increase” or “boost” breastmilk production BEFORE I use them.

I understand that I am responsible for informing the MC Lactation Specialist of changes I feel are necessary for her to know while she is assisting me with Lactation Services and during follow-up services.

I give my consent for the MC Lactation Specialist to release any information she has collected during our visit about myself or my baby to our healthcare provider, pediatrician, referring providers, and/or other Lactation Specialists should it be deemed necessary.

I understand that for this lactation visit and any follow-ups I may have, the MC Lactation Specialist will protect the privacy of my personal health information as required by law and the Health Insurance Portability and Accountability Act (HIPPA).

I allow a student or trainee be present and observe my consultation with the certified MC lactation specialist:(Required)
YES - A Student/Trainee can be present
NO - A Student/Trainee cannot be present

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PAYMENT OPTIONS FOR LACTATION VISIT

PAYMENT OPTION 1 - Pay with Zelle, Cash App or Venmo
MC accepts payments made by Zelle or Venmo as alternatives to payments made by credit or debit card.
TAP HERE FOR ZELLE & VENMO RECIPIENT INFORMATION
Zelle or Venmo Payments are made to: Dr. Marlo Robinson (MCDS President & Directress)

PAYMENT OPTION 2 - Pay with a Debit or Credit Card
Methods of Payment Accepted: Visa, MasterCard, American Express, Discover

PAYMENT OPTION 2 - DEBIT/CREDIT CARD - SELECT TYPE OF VISIT

1 HOUR - VIRTUAL BF VISIT - With MC Lactation Specialist

2 HOUR - IN-PERSON BF VISIT - With MC Lactation Specialist

PAYMENT OPTION 2 - PRICING - Select all that apply:

$200.00 - 1 HOUR - VIRTUAL BF VISIT

$400.00 - 2 HOUR - IN-PERSON BF VISIT

$100.00 - IMMEDIATE FEE (Additional & If Applicable - Services within 48 business hours notice)

PAYMENT OPTION 2 - DEBIT/CREDIT CARD - Total Amount to be Charged:

Payment Receipt will be sent separately.

PAYMENT OPTION 2 - DEBIT/CREDIT CARD - Visa, MasterCard or American Express

Cardholder Name

Card Details

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REFUND-CANCELLATION POLICY:

MC LACTATION VISITS ARE NON-REFUNDABLE - There are No Exceptions. While visits are non-refundable, they are transferable. You may transfer your payment to another MC Service. You have 30 days from the date of your paid registration to be transferred to another MC Service. If this time expires, you are responsible for the entire payment. No refund or discounts will be issued. To request a transfer to another service, please contact us as soon as possible. There are times, due to circumstances beyond our control, where your MC Lactation Specialist may have to reschedule your visit. Should this occur, we will contact you as soon as possible in order to provide new date and time options. There are no refunds or discounts for rescheduling. Instead, MC has 30 days from the date of your payment to reschedule your visit.

PAYMENT AUTHORIZATION & ALTERNATE PAYMENT DISCLAIMER

I authorize Mother’s Care Doula Services, Inc. (MC) to charge my card in the amount listed above for one or more prenatal classes based on the selections I have made on this form.

If I choose to pay using an alternate payment method such as Zelle or Venmo, I understand that my registration and class confirmation are not complete until full payment has been received and verified by MC. I am solely responsible for ensuring that payments are sent to the correct recipient and that the payment information matches that of MC’s President and CEO, Dr. Marlo Robinson. I understand that Mother’s Care Doula Services, Inc. is not liable for payments sent in error or to an incorrect recipient. If I send funds to the wrong person or entity, I understand that it is my sole responsibility to recover those funds directly from the party to whom payment was sent. If I have questions about a charge or believe I have been billed incorrectly, I agree to contact Dr. Marlo Robinson, President & CEO, at (305) 979-2823 or momsdoula@mcdsonlinedoulas.com for resolution.

WHAT HAPPENS AFTER I SUBMIT THIS FORM & SEND MY PAYMENT?

A Confirmation Email will be sent to the email address you included in this form. PAID BY DEBIT/CREDIT CARD - A receipt of your payment will be sent to you from momsdoula@mcdsonlinedoulas.com with your Confirmation Email. PAID BY PAYMENT APP - A receipt of your payment will be sent to you via the payment App you chose.

These forms are copyrighted and cannot be copied/used/reproduced without our authorization.

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LACTATION INTAKE FORMMeet with an MC Lactation Specialist

REGISTRATION FORM - Lactation Intake & Payment Form

BABY'S BASIC INFORMATION:

REASONS YOU NEED ASSISTANCE:

PAIN & CURRENT CHALLENGES

MILK SUPPLY CONCERNS & CHALLENGES

BREASTFEEDING CONCERNS & CHALLENGES FOR MOM:

BREASTFEEDING CONCERNS & CHALLENGES FOR BABY:

CURRENT HEALTH & HISTORY (MOM):

CURRENT HEALTH & HISTORY (BABY):

FORMULA SUPPLEMENT:

BREAST PUMP INFORMATION:

FINAL THOUGHTS or CONCERNS:

CONSENT & AUTHORIZATION

PAYMENT OPTIONS FOR LACTATION VISIT

REFUND-CANCELLATION POLICY:

WHAT HAPPENS AFTER I SUBMIT THIS FORM & SEND MY PAYMENT?

LACTATION INTAKE FORM
Meet with an MC Lactation Specialist