Lactation Consultant Appointment Request

Lactation Consultant Appointment Request — Form Fields

This healthcare template includes 11 fields. New mothers request an appointment with a certified lactation consultant for breastfeeding support. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Email Address (email, required)
• Phone Number (text, required)
• Baby's Date of Birth (text, required)
• Feeding Method Currently Using (dropdown selection, required) — options: Exclusively Breastfeeding, Combination Feeding, Exclusively Pumping, Formula + Attempting to Nurse
• Primary Concern (dropdown selection, required) — options: Latch Difficulty, Low Milk Supply, Pain with Nursing, Pumping Output, Return to Work Planning, Other
• Has baby been seen by pediatrician? (dropdown selection, required) — options: Yes, No, Scheduled
• Insurance Coverage for Lactation Services? (dropdown selection, required) — options: Yes, No, Unsure
• Preferred Appointment Date (text, required)
• Appointment Format (dropdown selection, required) — options: In-Person, Home Visit, Telehealth
• Additional information or questions (long text, optional)