Client Contact

Infant's First Name*

Infant's Last Name*

Sex of Baby*

Gestational Age at Birth*

Infant's DOB*

Mother's First Name*

Mother's Last Name*

Partner's First Name

Partner's Last Name

Sibling(s)'s Name(s)

Email*

Phone*

Address*

Other Health Care Providers (GP/Paediatrician/Allied Health)*

Health Fund*

Referral Source*

Reason for Consultation*

Consent Statement*
I understand that a consultation will include a visual and manual examination of my breasts and my infant's mouth. I give permission to a little help to share pertinent information about this and subsequent consultations with relevant health care professionals, as needed.