Schedule

Schedule an In-Home Lactation Consultation with The Mother’s Milk Company^sm

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

Client Information Form

To schedule an In-Home Consultation, fill out the form below. We will contact you shortly if we have not already spoken by phone or email. Thank You!

Mother/Birth Parent's Information

1. Mother/Birth Parent's Name(required)
2. Partner's Name
3. Mother's Date of Birth
4. Address
5. City
6. StateILINMICHWIS
7. Zip Code
8. Phone Number
9. Cell Phone Number
10. Email(valid email required)
11. Location of Delivery
12. Obstetrician or Midwife Name
13. Obstetrician or Midwife Phone Number
14. Obstetrician or Midwife Fax Number
15. Mother's Occupation
16. Length of Maternity Leave
17. Referred By

Infant's Information

1. Infant's Name
2. Infant's Date of Birth
3. Infant's Due Date
4. Infant's Physician
5. Infant's Physician Phone Number
6. Infant's Physician Fax Number
7. Infant's Birth Weight lbs
8. Infant's Birth Weight Oz
9. Discharge Weight lbs
10. Discharge Weight Oz
11. Discharge Date
12. Follow-Up Weight lbs
13. Follow Up Weight Oz
14. Follow-Up Date
15. Insurance Company Name

Reason for Visit

1. 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.
2. Captcha