Intake Forms

Forms Must Be Complete for New Patients

Please Complete All Forms below.

(Form 3 is for Postpartum moms only)

Consent Form
FORM 1
Release of Information Form
FORM 2
Assessment Form
FORM 3 - Postpartum Only
Intake - Consent Form

Consent Form



I authorize
I Have Received A Copy
I Give Permission
I Give Permission
I Understand
I Understand
I Understand
I Understand
I Understand
I Understand
I Understand
I Understand
I Understand
Intake - ROI Form

Release of Information Form



I Authorize and request Krystal Throne of Land of Milk and Babies to send and disclose my protected medical record and covered entities of HIPPA-identified information, including all notes to my physician listed on file and stated below.

Combined Report Of

Combined Report Of:

Parent:

Child:

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or distribution of this type of information.

This authorization is given in compliance with the federal consent requirements for the release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived.


Physician(s) for record to be released:

Physician(s) for record to be released:

A - Physician

A - Physician Address
A - Physician Address

B - Physician

B - Physician Address
B - Physician Address
Intake - Assessment Form

Assessment Form



DID YOUR BABY WEIGH MORE THAN 5.5 LBS AT BIRTH?
DID YOUR BABY WEIGH MORE THAN 5.5 LBS AT BIRTH?

DOES YOUR BABY FEED AT YOUR BREAST/CHEST?
DOES YOUR BABY FEED AT YOUR BREAST/CHEST?

DO YOU FIND IT CONVENIENT TO NURSE WHEN YOUR BABY WANTED TO NURSE?
DO YOU FIND IT CONVENIENT TO NURSE WHEN YOUR BABY WANTED TO NURSE?

IS YOUR BABY FUSSY AT TIMES?
IS YOUR BABY FUSSY AT TIMES?

HOW MANY BOWEL MOVEMENTS HAS BABY HAD IN THE LAST 24 HOURS?
HOW MANY BOWEL MOVEMENTS HAS BABY HAD IN THE LAST 24 HOURS?

ARE THE BOWEL MOVEMENTS YELLOW?
ARE THE BOWEL MOVEMENTS YELLOW?

DOES YOUR BABY HAVE AT LEAST 6 WET DIAPERS A DAY?
DOES YOUR BABY HAVE AT LEAST 6 WET DIAPERS A DAY?

DOES YOUR BABY SLEEP SOUNDLY BETWEEN FEEDINGS?
DOES YOUR BABY SLEEP SOUNDLY BETWEEN FEEDINGS?

DOES YOUR BABY WAKE TO NURSE ON HIS/HER OWN BEFORE 3 HOURS HAVE PASSED?
DOES YOUR BABY WAKE TO NURSE ON HIS/HER OWN BEFORE 3 HOURS HAVE PASSED?

HOW DO YOU KNOW IT IS TIME TO FEED THE BABY?

DO YOU OFFER THE BREAST FOR COMFORT IN ADDITION TO FEEDINGS?
DO YOU OFFER THE BREAST FOR COMFORT IN ADDITION TO FEEDINGS?

IF YOUR BABY WAS FUSSY, WOULD YOU BE MORE LIKELY TO:
IF YOUR BABY WAS FUSSY, WOULD YOU BE MORE LIKELY TO:

IF YOUR BABY WAS FUSSY, WOULD YOU BE MORE LIKELY TO:
IF YOUR BABY WAS FUSSY, WOULD YOU BE MORE LIKELY TO: