TO SCHEDULE THE VISIT SUITED TO YOUR NEEDS,  CALL 413-529-2200

ALL VISITS can use the following payment methods:  Visa , Mastercard, American Express , Cash , Check or
 
MEDELA BREAST  PUMPS available for rental as well as additional breastfeeding products for sale including pump accessories, nipple shields, supplementary feeding systems, etc.

Pioneer Valley Lactation Consulting does not accept heath insurance but a detailed receipt will be available to you.

GIFT  CERTIFICATES are available by calling 413-529-2200. They make a unique and thoughtful baby shower gift!

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TO HELP make our visit more productive, please fill out the form below prior to your visit and click "SEND" to submit the form.
  
CONSENT FORM for CONSULTATION
I understand that a consultation may include a visual and manual examination of my breasts and the baby's mouth. I give permission for information from this and subsequent consultations to be shared with my baby's pediatrician and my own health care provider if appropriate. By clicking "SEND" below you agree to these terms.

Name:
Name of Significant Other:
Address:
City, State, Zip:
Phone:
Email:
Number of Pregnancies:
Number of Children:
Have You Breastfed Before?	Yes No
Any complications or concerns with this pregnancy?	Yes No
Date of Delivery:
Type of Delivery:
Length of Labor:
Any complications during labor?	Yes No
Name of Your Provider:
Allergies:
Daily Medications:
Occasional Medications:
Health History:
Past Surgery:
Name of Baby:
Any complications since birth?	Yes No
Your concerns for this visit:
Please click the "Send" button only once.