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 have a virtual consultation.

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)
Tick in the box that you consent for and are aware of the following
Have you or any other member of your household been suffering from any symptoms of the coronovirus such as a persistant dry cough and or a temperature.
Maternal or family history of any bleeding or clotting disorders? (bleeding easily)
Maternal or family history of HIV, Hepatitis B or C
Family history of tongue-tie?
Maternal medical conditions - please tick all that apply
Current medication
Initiation of labour
Birth method
Pain relief
3rd stage of labour / delivery of placenta
Vitamin K given?
Baby's medical history
Osteopathic assessment or treatment
Current feeding method
Current feeding / baby concerns - please tick all that apply
Current maternal concerns - please tick all that apply
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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