Booking Request | Latched N Love

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Latched-N-Love, LLC

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*First name

*Last name

*Phone

*Email

Address

*Mother's Date of Birth

*Baby's Due Date

Baby's Birth Date

Baby's Gender

Type of Delivery

Prenatal or Postpartum?

*How would you like to be seen?

*Appointment Urgency

*Type of Support Needed — select all that apply

Prenatal breastfeeding education

Initial postpartum lactation consultation

Flange fitting / pumping assessment

Low milk supply concern

Oversupply concern

Latch / feeding assessment

Bottle-feeding support

Returning-to-work consultation

Relactation / induced lactation

Weaning consultation

General breastfeeding guidance

Other

What Are You Experiencing? — select all that apply

Nipple pain or damage

Breast pain

Engorgement

Plugged ducts / breast inflammation

Mastitis or suspected mastitis

Low milk supply / supply concerns

Delayed milk production

Oversupply / forceful letdown

Pumping difficulty

Flange fit concerns

Breast/nipple infection or suspected thrush

Other maternal concern

Baby/Infant concerns

Difficulty latching

Sleepy or ineffective feeding

Baby seems hungry after feeding

Poor milk transfer

Weight loss / slow weight gain

Low diaper output

Breast refusal / nursing strike

Bottle-feeding difficulty

Coughing/choking/gagging during feeds

Clicking/leaking milk while feeding

Reflux/spit-up concerns

Suspected tongue or lip tie

Prematurity/NICU feeding concerns

Other infant concern

Anything I Should Know When Scheduling?

Premature/NICU graduate

Multiples

Medically complex infant

Recent/planned tongue- or lip-tie procedure

Currently seeing feeding therapy/SLP/OT/PT

Currently seeing a feeding-related specialist

None of the above

Other

Insurance / Payment

Cigna

Anthem

Self-pay

Unsure

Insurance coverage is subject to eligibility and benefit verification and is not a guarantee of payment.

Acknowledgments

I understand this is an appointment request and does not confirm an appointment.

I understand Latched-N-Love will contact me to confirm availability and scheduling.

I understand this form is not monitored for medical emergencies.

I consent to being contacted regarding my appointment request.

Latched-N-Love, LLC

346-213-3367

arlynj@latchednlove.com

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