Lactation Consultation Service

Referral to Lactation Consultant

• Antenatal/Postnatal *

  Antenatal   Postnatal

• Mother's Name *

• NHI *

• Age *

• Address *

• Phone number *

• Second phone number

• Ethnicity *

  NZ European   Maori   Pacific   Asian   Other

• Baby’s Name

• Date of Birth *

• Baby's Ethnicity

  NZ European   Maori   Pacific   Asian   Other

• Reasons for Referral

• Maternal Issues

  Nipple or Breast Anomalies   Nipple Pain / Trauma   Mastalgia / Mastitis and complications   Insufficient Milk Supply   Hyperlactation   Breastmilk feeding / Expressing   Induced Lactation / Relactation   Returning to Work   Medication in Mother’s Milk   Cessation of Breastfeeding   Other (details)

• Baby Issues

  Preterm / Small for Gestational Age   Latching Difficulties   Tongue-Tie   Jaundice / Breast milk jaundice   ‘Colic’ / Intolerance / Allergy / Reflux   Thrush   Slow Weight Gain / Failure to Thrive   Twins or More   Anomalies / Diseases / Disorders   Solid Foods   Other (details)

• Please outline your current/existing plan to address breastfeeding issues for this mother and infant *

• Referrer *

• Profession *

• Phone/Fax

• Address

• Email Address *

• What is 4 + 4 *