Schedule a consultation with an IBCLC from The Mother's Milk Company

We are experiencing website difficulties. Please do not submit the form below at this time as we are not able to receive them. Instead call or email at the number/address below and we will be happy to assist you as soon as possible.

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(required)
Partner's Name
Mother's Date of Birth
Address
City
State
Zip Code
Phone Number
Cell Phone Number
Email(valid email required)
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
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(required)
Reason for Visit
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