LACTATION INTAKE FORMMeet with an MC Lactation Specialist REGISTRATION FORM - Lactation Intake & Payment Form Title of the document 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 Title of the document 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 are scheduled within 72 hours of requesting an appointment. Review the info above about Virtual Visits to determine if this is the best option for you based on what kind of assistance you need. In-person Visits: When possible, In-person visits can be coordinated within 3 - 7 business days of requesting an appointment. If you feel you are experiencing an emergency and require an immediate visit (within 48 hours), please contact MC HERE or at (954) 433-CARE (2273). We may be able to coordinate it for an additional, Immediate Service Fee. Review the info above about In-person Visits to determine if this is the best option for you based on what kind of assistance you need. Title of the document 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 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 emptyHow did you hear about us? If you were referred to us, please tell us who referred you (first & last name):(Required) Title of the document BABY'S BASIC INFORMATION:HAS THE BABY BEEN BORN?(Required) YES NO 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: Title of the document 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? Title of the document 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. Title of the document 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 No Form Completed Prenatally: I haven't started nursing/pumping. Are you experiencing Nipple Cracking and or Bleeding?(Required) Yes No Form Completed Prenatally: I haven't started nursing/pumping. Are you currently experiencing "Engorgement"?(Required) Yes No 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 No 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 No 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? Title of the document CONSENT & AUTHORIZATIONCONSENT 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 Title of the document PAYMENT OPTIONS FOR LACTATION VISITPAYMENT OPTION 1 - Pay with Zelle, Cash App or Venmo PAYMENT OPTION 1 - PAYMENT APP - Select Preferred App Zelle App - Connect to your Payment App Venmo App - Connect to your Payment App Open your Zelle or Venmo App to make your payment. CLICK HERE FOR RECIPIENT INFOPAYMENT OPTION 1 - PAYMENT APP - Select all that apply: $200.00 - 1 HOUR - VIRTUAL BF VISIT $400.00 - 2 HOUR - IN-PERSON BF VISIT SERVICE TRANSFER - Transferring from another MC Service (Pay Remaining Balance) CLICK HERE: APP DETAILS & RECIPIENT INFO (ZELLE or VENMO)PAYMENT APPS: Make your payment as soon as possible. If your payment is not received, we cannot confirm your appointment. SERVICE TRANSFERS: If approved to transfer your payment from a previous MC Service, payment is required for any differences in service pricing and or any additional fees. Service Transfer Payments can be made by Zelle or Venmo Payments ONLY. If you have questions about using a Payment App for your Lactation Visit, please contact MC HERE.PAYMENT OPTION 2 - Pay with a Debit or Credit Card 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 +$200.00 $400.00 - 2 HOUR - IN-PERSON BF VISIT +$400.00 PAYMENT OPTION 2 - DEBIT/CREDIT CARD - Visa, MasterCard or American Express Cardholder Name Card Details PAYMENT OPTION 2 - DEBIT/CREDIT CARD - Total Amount to be Charged: Payment Receipt will be sent separately. Title of the document Title of the document REFUND-CANCELLATION POLICY & TRANSFER OF SERVICES: 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. WHAT HAPPENS AFTER I SUBMIT THIS FORM & SEND IN MY PAYMENT? A Confirmation Email will be sent to the email address you provided within 72 hours. 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.CommentsThis field is for validation purposes and should be left unchanged.