BAY AREA BREASTFEEDING SUPPORT
Bay Area RN Lactation Consultant
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Book an Appointment by filling out this form!
Please Enter Insurance Information so we can offer you a superbill for INSUANCE reimbursement.
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Birthing Parent's Name
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First
Last
legal first and last name
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Birthing Parent's Date of Birth
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Baby Name
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First
Last
if no name yet feel free to make something up :)
Baby Date of Birth
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Pediatrician/Midwife
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OBGYN/Midwife
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I am interested in:
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Lactation Consults
Prenatal Breastfeeding Classes
Bottle Consults
Weaning Consults
Video Consults
I prefer contact back via the following methods. (TIP! Check your Spam folder in the next 12 hours since our email may go there!)
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Email
Text
Call
What is a brief summary of your concern?
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Are you primary (the owner) on your insurance? Name and full date of birth of the primary please!
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Name of your Insurance. Insurance ID Number and Group Number!
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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).
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May a Lactation Intern be present during our consult? This intern will be full vaccinated.
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I consent to wear a mask during our visit in person, I will cancel our appointment if I have been sick within the last 5 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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yes
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Bay Area RN Lactation Consultant
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