Schedule a consultation with an IBCLC from 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 *