Deeply Latched Lactation

Healthy Start Lactation Referral Form

IMPORTANT CHANGE DOULAS AND HOME VISITORS: Instead of listing your name, give client's name and phone number/email in the two fields below- do not put your phone number as stated.

Your name can be added when you open the form when you add their HS number and address. This creates a profile in my EHR where I can automatically contact them- thank you for helping me make this change! I don't want to miss your referrals and I can’t change what’s written in the field.

You can also save this for your records if you'd like.

Healthy Start Lactation Referral Form

Please enter Healthy Start Client's name and their phone number/email where it says “Your number”