Lactation Consultant Referral - NBPH - nbph org 2026

1. Click ‘Get Form’ to open the Lactation Consultant Referral form in the editor.
2. Begin by filling in the 'Referred By' section, including your name, position, and date. Ensure you provide accurate contact information such as phone number and email.
3. Next, enter the baby's name, mother's name, date of birth (DOB), and National Health Index (NHI) for both mother and baby. This information is crucial for proper identification.
4. Complete the gestational age at birth and parity fields. Then select the ethnicity options for both mother and baby by checking the appropriate boxes.
5. Fill in the birth weight, current weight and age of the baby, and specify the birth mode (vaginal or caesarean).
6. Indicate smoking status and confirm if maternal consent has been obtained for referral. Provide any relevant birth or breastfeeding history.
7. Select services involved in care from the provided options. Lastly, detail reasons for referral for both baby and mother by checking applicable boxes.
8. Summarize what has been tried regarding breastfeeding plans to date before submitting your completed form.

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