Breastfeeding Help Near Me | Breastfeeding Help | BABS

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Your Name *

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Your Date of birth *

Baby Name *

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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 summary of the concerns you have? Please list any underlying health issues such as PCOS, Gestational Diabetes, Postpartum Hemorrhage, C-section Delivery, Preterm Labor, IUGR Baby, Infant Cardiac Defects, Breast Reduction or Augmentation Surgery, History of Breast Radiation, Thyroid Problems, Infant Jaundice, Forceps Delivery, High Infant Weight Loss, or problems breastfeeding any prior children: *

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). *

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