Penny Heywood – Classical Homeopath (R.S. Hom) & Lactation Consultant (IBCLC) serving the community of Brockley and South East London
It will be helpful if you can provide the following information prior to an appointment.
Date of Birth*
MF
Infant Date of Birth*
Please give details about why you would like a consultation:
Please note any advice to date from your healthcare provider or other breastfeeding support services you may have accessed:
GENERAL MEDICAL BACKGROUND
Are you a smoker? YesNo
MENTAL HEALTH
Anything else of note:
OBSTETRIC
Labour: VaginalAssistedC sectionMedicationComplicationsSkin to skinBreastfeeding after birth
Health Issues: JaundiceInfectionNICUWeightTongue tieRefluxThrushOral abnormalitiesOther
INFANT FEEDING HISTORY Please give a brief summary of feeding so far including use of bottles, formula, expressing, nipple shield use, and dummies
(ALL 3 ARE REQUIRED)
For insurance purposes, I am required to obtain the following consents prior to a Breastfeeding consultation.
I give my consent for Penny Heywood, Lactation Consultant (IBCLC) work with me. This includes: observing a complete breastfeed and manual examination of the breast and/or examination of baby - if necessary.
I give my consent for Penny Heywood, Lactation Consultant (IBCLC) to share appropriate information with Healthcare Professionals (Midwife, Health Visitor or GP), if considered necessary.
I give my consent for Penny Heywood, Lactation Consultant (IBCLC) to contact me by telephone or email (if necessary) to provide information and ongoing support.
I have read and understood the above and I give my informed consent for a Breastfeeding consultation. Today's date*
