Appointment Request Form

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Child Date of Birth or Estimated Due Date

MM

DD

YYYY

How soon do you need an appointment?

As soon as possible

In the next 2-3 days

Next week or later

Do you prefer a home or office consult?

Home consults are reserved for the first 2 weeks postpartum within a designated driving area.

Home Consult

Office Consult

First Available

Lactation Consultant Preference

Meredith Wentzel, MA, LMBT, IBCLC

Ashley Nickerson, BSN, RN, IBCLC

Margaret Brannon, BSN, RN, IBCLC

Julia "Allie" Porter, IBCLC

Paige Hymna, RN, CLC

First available consultant

What can we help you with?

Check all that apply.

Adoption/Surrogate/Induced Lactation

Breastfeeding

Bottle Feeding

Group Class Enrollment

Infant Not Latching

Low Milk Supply

Prenatal Support

Pumping

Sore, Cracked, Bleeding or Pain

Tongue and Lip Ties

Twins/Multiples

Other