Breastfeeding Help Near Me | Breastfeeding Help | BABS

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Birthing Parent's Name *

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Birthing Parent's Date of Birth *

Baby Name *

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Baby Date of Birth *

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I prefer contact back via the following methods. (TIP! Check your Spam folder in the next 12 hours since our email may go there!) *

What is a brief summary of your concern? *

Are you primary (the owner) on your insurance? Name and full date of birth of the primary please! *

Name of your Insurance. Insurance ID Number and Group Number! *

Informed Consent and Release. I give my consent for Bay Area Breastfeeding Support (BABS) to work with me and my baby concerning our breastfeeding situation. This consent is for in-person visits, telephone conversations, and/or information sent by e-mail, fax or regular mail, and includes appropriate follow-up contacts. I give consent for BABS, to perform any or all of the following: Observation of the mother and infant feeding; Analysis of the available data relating to the breastfeeding situation; Demonstrate techniques for improving breastfeeding and, where appropriate, the use of breastfeeding equipment; Visual and physical assessment of the mother’s breasts which may involve physically touching the mother’s breasts; Visual and physical assessment of the infant’s mouth, which may involve insertion of gloved fingers in the mouth of the baby. I understand that all medical care for myself and my baby is to be provided only by my/our own physician(s). I give permission for information about this and all additional consultations to be shared with and sent to (by electronic or other means) my physician(s) and/or other health care provider(s). *

May a Lactation Intern be present during our consult? This intern will be fully vaccinated. *

I will cancel our appointment if I have been sick within the last 3 days, I understand that Serena is vaccinated against covid-19 and all other transmittable diseases, I understand that Serena wears her mask during the visit and will not see you if she has any symptoms of illness. *

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