Natashia Conner &

B.R.E.A.S.T. 4 BABES

Black Breastfeeding

The CENTER of EDEN

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Intake Forms

First Name

Phone

Patient Gender at Birth

Last Name

Date of Birth (Birthing Parent)

Select an Address

Number of Pregnancies

Number of Live Births

Due Date or Infant Date of Birth

Race

Ethnicity

Best way to contact you:

Name of Insurance Provider

Insurance ID

Coverage Code

Group #

Insurance Carrier * Required

Medicaid/ Medicare

Private/ Commercial

No Insurance/ Cash

Other

Birth Method

Breastfeeding goal

Have you breastfed before?

Are you returing to work?

Pregnancy status

Significant Medication:

Select all that appy: * Required

Gestational Diabetes

Diabetes Mellitus Type I/ II

(pre) eclampsia

Postpartum hemorrhage

Hypo/hyperthyroid disease

PCOS

Depression

Substance abuse

Smoke

Alcohol

Breast reduction

Breast surgery

Breast augmentation

Blood transfusion

Magnesium during/after birth

IV fluids during birth

Mother’s PCP (Primary Care Provider):

Infant’s PCP (Primary Care provider):

Delivering Hospital:

Cheif Complaint * Required

Nipple pain/ discomfort

Milk supply

Back to work

Pumping

Weight gain/ weight loss

Latch difficulty

Weaning

NICU infant

Additional complaints or complications:

Select an item ($) *

Home Visit Retainer (Non-refundable) - $75

Virtual Visit Retainer (Non-refundable) - $50

Cancelation Fee (Non-Refundable) - $30

I agree to the terms & conditionsInformed Consent Agreement.

Your Signature

Thank you for trusting me to be a part of your breastfeeding experience. This is an honor that I do not take lightly and will strive to provide you with the best care needed throughout your breastfeeding journey. The information provided will not be shared without your consent and only with those individuals specified by you for our continuum of care. Example: Birth Doula, Pediatrician, or your Primary Care Provider. Please email additional information to: info@RHEcorp.org

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If your health insurance plan is one of the few that isn't required to cover breastfeeding support and counseling, or you're not interested in submitting for reimbursement, you should be aware that home visits from an IBCLC are eligible Health Savings Account (HSA) expenses. If you have an HSA through your work or your insurance company, you can use your superbill to submit for reimbursement from your HSA funds- you may even be able to use your HSA debit card to pay for the visit.

Non-refundable deposit retainer (home visits): $75.00 *COVID-19 precautions per CDC, 10 mile radius from downtown Cincinnati

Non-refundable deposit retainer (virtual visit): $50.00

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All information provided on this website, including all texts, images, and other material are for informational purposes only and should not be considered a replacement for assessment or treatment by a healthcare provider.

Intake Forms

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