Please fill out the following form and submit. Please submit 24 hours prior to the consult Mom and Baby information Form - All About Breastfeeding - Lori J Isenstadt IBCLCYour Name Your Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryYour Phone Number Email Your Babies Name Your Babies Place of Birth Your babies Date of Birth Your Babies Birth Weight Mom's Health Care Provider - Doctor or Widwife Birth Vaginal BirthCesarean BirthBirth Complications YesNoIf yes - Please explain Health Issues that I should know about Prescription drugs? Over the counter? Herbs? Please list them Infertility Issues? YesNoExplain Breast Surgery? YesNoThe following is babies informationIf so, date and what procedure was done? List any complications? Pediatricians name and website List pediatrics visits - List dates and weights and specific instructions as a result of the visit. Please share breastfeeding history leading up to the time of your Skype Consult. For example: pumping,supplementing, nipple shield use, painful breastfeeding? Consent to share Information I, __________________________, give permission for information provided in this intake form to be shared with my and my infant’s, healthcare providers. I give permission for the information collected (with the exception of my, and my infant’s, names) to be used for educational purposes and I will be notified how and when it is used for educational purposes (i.e. to help train aspiring lactation consultants). I understand that this consultation is confidential, and that unsafe situations for mom or baby will be reported as required by law.Electronic Signature here Consent for consultation - Office or Home or Skype A lactation consultation usually includes visual and physical (via touching) assessment of a mother’s breast and infant’s mouth and body’s anatomy, observation of the mother and infant nursing, analysis of data related to the breastfeeding situation, demonstration of breastfeeding techniques and can include the use of breastfeeding equipment. I give permission to Lori J. Isenstadt, IBCLC to perform all of the above with the purpose of providing breastfeeding care Mom’s Signature and DateElectronic Signature here VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: