Lactation Foundation General Referral Form

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Referral to The Lactation Foundation

Please complete the fields below and click submit at the end of the form - we will not receive your form unless you click submit.

You will be able to upload any relevant visit notes or documents before you submit the referral request. You may also email these items to m egan.kindred@uth.tmc.edu after you submit your referral.

Referring Provider Information

The REFERRING PROVIDER is a (check all that apply):

Physician
Physician Assistant/Associate
Nurse Practitioner
Nurse
IBCLC
Other (please specify)

Referring PROVIDER's name (FIRST and LAST):

Referring PROVIDER phone number:
Please enter a number where you can be reached. This info will not be shared with patients or other providers.

Would you like to receive a copy of the visit notes resulting from this patient's referral?

Yes. My fax number is:
No

Patient Information

Please enter the patient's name (FIRST and LAST):

Please enter the patient's DATE OF BIRTH:

Please enter the patient's PHONE NUMBER:

Please select the diagnosis or reason you are referring this patient (select all that apply:

Infant

Slow feeding of newborn P92.2
Underfeeding of newborn P92.3
Neonatal difficulty in feeding at the breast P92.5
Failure to thrive in newborn P92.6
Failure to thrive in child over 28 days old R62.51
Other feeding problem of newborn P92.8
Abnormal weight loss R63.4
Abnormal weight gain R63.5
Underweight R63.3
Ankyloglossia Q38.1
Congenital malformations of palate (high arched palate) Q38.5
Other (please specify)

Parent

General lactation concerns / encounter for care and examination of lactating mother Z39.1
Cracked nipple associated with lactation O91.13
Nonpurulent mastitis associated with lactation O91.23
Hypogalactia (low milk supply) O92.4
Unspecified disorders of lactation O92.70
Mastodynia (breast pain) N64.4
Other (please specify)

Number of visits requested:

Initial evaluation only
Initial evaluation and # of follow up visits as indicated here:
Initial evaluation and follow ups as needed

Requested provider:

First available provider / appointment
Megan Kindred, APRN, FNP-C, IBCLC
Kelsie Barta, APRN, FNP-C, IBCLC

Enter any other relevant details here (or you may attach visit notes below):

Please attach any relevant visit notes or other documents here:

Referring Provider Signature:

Sign Here

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