Intake Form

LIQUID GOLD LACTATION MOTHER/INFANT SUPPORT

Home
Services
- Drop in Clinic RSVP
- Class sign up
Contact
Meet Jodi the LC
Resources
4th Trimester
Education
Testimonials
Milk Supply 101

Home
Services
- Drop in Clinic RSVP
- Class sign up
Contact
Meet Jodi the LC
Resources
4th Trimester
Education
Testimonials
Milk Supply 101

Brief Client Intake Form

* Indicates required field

Name *

First

Last

Phone Number *

Baby's name *

First

Last

Email *

Preferred method of contact *

Email, phone, text?

Symptoms/issues experiencing (tick off as many as are applicable and feel free to add details in the symptoms cont'd box. *

Low milk supply Over supply of milk Poor infant weight gain Tongue/Lip ties Nipple damage or breast pain Plugged ducts, mastitis, thrush Bloody stools/food sensitivities Frequent feeder Sleep issues Gas, colic, spit ups, reflux Poor infant head shape Poor infant milk transfer, ineffective feeding

Symptoms cont'd *

Has your baby had any bodywork since birth? (Chiropractic/Osteopathy/Craniosacral Therapy) Yes/No. If Yes, which kind? *

How old is your baby? *

Not born yet / still pregnant 0-7 days old 8-14 days old 2-4 weeks old 4-6 weeks 6-8 weeks 2 months 3 months 4 months > than 4 months

Would you prefer (there is a fee for one on one visits): *

Home visit Clinic visit Hospital visit

If you'd rather a home visit, what city do you live in? *

Submit

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Hours

Flexible

Telephone

604-897-1700

Email

liquidgoldbfs@gmail.com