Prenatal Lactation Services Intake Form

Prenatal Lactation Services Intake Form

Congratulations! 🎉 We're so excited for you and honored that you've chosen us to be part of your baby's journey. Thank you for trusting us with the health and well-being of your growing family. Please complete the form below so we can gather the information needed to create your account, schedule your prenatal lactation consultation, and connect you with our lactation services. We look forward to supporting you every step of the way!
About the Mother

Expectant Mother Details
Name

First NameMiddle NameLast Name
Date of Birth

DayMonthYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
About the Baby

Delivery & Baby Details
Name (Leave Blank if Undecided)

First NameMiddle NameLast Name
Expected Delivery Date

MonthDayYear
Date
Planned Hospital of Delivery
Name of Obstetrician
Dependents

Other Siblings
Do you have other children that are currently a patient at Piedmont Pediatrics?
If yes, please list their names and date of birth below:
Current Patient's Name

First NameLast Name
Current Patient's Date of Birth

MonthDayYear
Date
Current Patient's Name

First NameLast Name
Current Patient's Date of Birth

MonthDayYear
Date

Prenatal Lactation Consultation Consent Form
Provider Name (NP): Lynn Dolan, NP
Practice Name: Piedmont Pediatrics, LLC

Purpose of Visit

I understand that this visit is a prenatal lactation consultation intended to provide education, guidance, and preparation for breastfeeding. Topics may include breastfeeding techniques, expectations, and common challenges.

Nature of Services and Care Team

I understand and acknowledge that:

This service is provided by a Nurse Practitioner (NP) who is also a certified lactation specialist, working under a supervising physician in accordance with Georgia law and the practice’s supervisory agreement.
The NP is acting within their approved scope of practice, which includes lactation education and counseling for pregnant patients.
The supervising physician is available for consultation, collaboration, and oversight as appropriate.
This visit is educational and preventive in nature and does not establish obstetric care with this provider.

Scope and Limitations of Services

I understand that:

This consultation is not a substitute for obstetric, gynecologic, or primary medical care.
The NP will not diagnose or treat pregnancy-related medical conditions.
The NP will not provide obstetric medical advice, medication management, or clinical decision-making outside lactation education.
No infant assessment or care is provided during prenatal visits.
Postpartum follow-up may be recommended after delivery for lactation support.

If medical concerns are identified (such as a breast mass, infection, or other symptoms), I will be referred to my obstetric provider or appropriate healthcare provider for evaluation and treatment.

Chaperone Option

I understand that portions of this visit may involve physical assessment or observation (e.g., breast evaluation or positioning guidance).

A chaperone is available upon request for any portion of the visit.
I may request a chaperone at any time.
Chaperone Preference (optional):
No Guarantee of Outcomes

I understand that breastfeeding outcomes vary, and no guarantees have been made regarding my ability to breastfeed or achieve specific results.

Coordination of Care

I agree to maintain care with my obstetric provider and understand that this consultation is intended to support and complement—not replace—my prenatal medical care.

Voluntary Participation

I understand that:

Participation in this service is voluntary.
I may decline or stop participation at any time.
My decision will not affect my access to medical care at this practice.

Consent

I confirm that:

I have had the opportunity to ask questions, and my questions have been answered.
I understand the role of the Nurse Practitioner and supervising physician in this care model.
I understand the purpose, scope, and limitations of prenatal lactation consultation.
I voluntarily consent to participate in prenatal lactation consultation services.
Signature
Should be Empty:

Prenatal Lactation Services Intake Form

About the Mother

About the Baby

Dependents

If yes, please list their names and date of birth below: