Lactation Consultation Service

Antenatal/Postnatal*

Mother's Firstname*

Mother's Lastname*

NHI*

Age*

Address*

Street Address Suburb/Area City Country

Phone number*

Secondary phone number

Ethnicity*

Baby’s Name*

Date of Birth*

Baby's Ethnicity*

Reasons for Referral

Maternal Issues*

Baby Issues

Please confirm that you have observed an entire feed and document what adjustments you have suggested to the Mother in the following box*

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

Referrer*

Profession*

Phone*

Fax

Address*

Street Address City Country

Email Address*

* This information is required to submit this form. Thank you.

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It advisable prior to submission to print a copy of this referral for your clinical records