LIQUID GOLD LACTATION & MOTHER/INFANT SUPPORT
Home
Services
Class sign up
Contact
Meet Jodi the LC
Resources
Professionals
Tongue Function
Body Work
Infant exercises
Videos & Online Resources
Breastfeeding 101
Essential Oils
Local Retail
4th Trimester
Education
Testimonials
Home
Services
Class sign up
Contact
Meet Jodi the LC
Resources
Professionals
Tongue Function
Body Work
Infant exercises
Videos & Online Resources
Breastfeeding 101
Essential Oils
Local Retail
4th Trimester
Education
Testimonials
Brief Client Intake Form
*
Indicates required field
Name
*
First
Last
Phone Number
*
Baby's name
*
First
Last
Email
*
Symptoms/issues experiencing (if more than one please pick main concern and add the rest in the comments section)
*
Low or over supply of milk
Latch issues
Tongue/Lip ties
Nipple damage
Plugged ducts, mastitis, thrush
Poor weight gain
Gassy baby
Frequent feeder
Infant Regurgitation, spit ups, vomiting
Symptoms cont'd
*
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
Additional info you want me to know:
*
Submit