Did a Lactation Consultant refer you?
Other (I have not spoken to a consultant but I am hoping to work with a specific person.)
Name of Lactation Consultant
Preferred Lactation Consultant
How urgent is your need for a visit?
Emergent - need to be seen in the next 36 hoursUrgent - need to be seen within the next 72 hoursNon-Urgent - can wait 5 days for a visit
Mobile Phone Number (numbers only, XXXXXXXXXX)
District Of Columbia
Mom's Date of Birth (numbers only, YYYYMMDD)
Mom's Insurance Provider
Mom's Insurance ID
Mom's Group Number
Has your baby arrived?
Baby's Birth Date — If Baby Hasn't Arrived, Enter Expected Due Date (numbers only, YYYYMMDD)
Baby's First Name
Baby's Last Name
Is baby on your insurance?
Baby's Provider (Pediatrician, etc.), if applicable
Baby's Insurance Plan, if not on your insurance
Baby's Insurance ID, if not on your insurance
Baby's Group ID, if not on your insurance
I give the Lactation Network permission to share my information with contracted IBCLCs