PRE-CONSULTATION FORM

Luci Lishman RGN, RM, IBCLC

Lactation Consultant & Tongue Tie Practitioner

t : 07795 366251

e : info@chilternbreastfeeding.com

PRE-CONSULTATION FORM

This form is for you to complete once you have made an appointment to see us. 

This information will go through to our work email and will help save time during your consultation.

Please read our privacy notice first so you understand how we use and store your information.

We would appreciate you filling this in at least 6 hours before your appointment if possible.

Reason for consultation (tick all that apply)
Current feeding method
Current feeding / baby concerns - please tick all that apply
Current maternal concerns - please tick all that apply
Osteopathic assessment or treatment
Maternal or family history of any bleeding or clotting disorders? (bleeding easily)
Maternal or family history of HIV, Hepatitis B or Hepatitis C?
Family history of tongue-tie?
Birth method
Vitamin K given?
How did you hear about Chiltern Breastfeeding Partnership?
USEFUL LINKS & INFORMATION

Contact us to book a consultation or make an enquiry.  You can also book online for clinic appointments.

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