Schedule | The Mother's Milk Company

Call us: 773 595-5593
Email us: barbara@mothersmilkco.com.
Or complete the form below.

Client Information Form

To schedule an In-Home or Tele-Health Consultation, fill out the form below. We will contact you shortly if we have not already been in contact. Thank You!

Mother/Birth Parent's Information

Mother/Birth Parent's Name *

First

Last

Partner's Name

First

Last

Mother's Date of Birth *

Address *

City *

State

Zip Code

Phone Number *

Cell Phone Number

Email *

Location of Delivery

Obstetrician or Midwife Name

Obstetrician or Midwife Phone Number

Obstetrician or Midwife Fax Number

Birth Parent's Occupation

Length of Maternity Leave

Referred By *

Infant's Information

Infant's Name

First

Middle

Last

Infant's Date of Birth

Infant's Due Date *

Infant's Physician

Infant's Physician Phone Number

Infant's Physician Fax Number

Infant's Birth Weight Lbs

Infant's Birth Weight Ounces

Discharge Weight Lbs

Discharge Weight Ounces

Discharge Date

Follow-Up Weight lbs

Follow-Up Weight ounces

Follow-Up Date

Please give a brief description of your breastfeeding concerns and how we can help you. Indicate how you prefer to be contacted: phone, text or email.

Insurance Company Name *