Booking

Personal Information

First Name *

Last Name *

Date of Birth *

Street Address *

City

State/Province

ZIP / Postal Code

Preferred Method of Contact *PhoneEmail

Email Address *

Phone Number *

Pregnancy & Infant Details

Current Pregnancy Status *PregnantPostpartum

Due Date or Baby's Date of Birth *

Baby's Name(if applicable)

Baby's Age

Feeding Information

Current Feeding Method *BreastfeedingFormula FeedingCombination FeedingExclusive Pumping

Specific Feeding Concerns or Goals *Latching DifficultiesMilk Supply IssuesTransitioning Between Feeding MethodsReturning to Work and PumpingWeaning PlansSelect All That Apply

Medical & Birth History

Type of Delivery *VaginalCesarean SectionSelect All That Apply

Any Complications During Pregnancy or Birth?YesNo

If Yes, Please Explain

Relevant Medical History

Services Requested

Select Services *Tongue & Lip AssessmentEngorgement & Mastitis Relief StrategiesTwin & Multiples Breastfeeding SupportFeeding After C-Section GuidanceExclusive Pumping & Bottle-Feeding AssistanceNighttime & Sleep Feeding StrategiesSelect All That Apply

Preferred Appointment Type *In-Person ConsultationVirtual Consultation

Preferred Date *

Preferred Time *

Hours

Minutes

Support System

Primary Support Person *

Additional Support ResourcesAre you connected with any mother support groups?Do you have access to other healthcare professionals (e.g., pediatrician, obstetrician)?Check any that apply, if applicable

Emergency Contact *Person to contact in case of emergencies.

Relationship *Relation to the client.

Phone Number *Direct contact number.

Additional InformationReferralSocial MediaWebsiteGoogleOtherHow Did you Hear About Us?

Consent & Accuracy Agreement *

I confirm that the information provided in this form is accurate and complete to the best of my knowledge. I understand that this online consultation is based on the details I have submitted, and I consent to the electronic submission of this form.

Servicing

Effingham County & Surrounding Areas

Welcome to Lactation for Mothers & Babies!
I’m here to support you with expert advice and personalized care on your breastfeeding journey. Let’s make this experience beautiful and successful!

working hours

SUN - SAT: By Appointment Only