Phone Consultation Consent Form

Phone Consultation Consent Form
Theresa Wrublesky RN, CBC, CPD, CIME
215-860-8461
www.buxmontbreastfeeding.com
*As a Breastfeeding Counselor I cannot give medical advice or treatment. It is up to my discretion whether your problem can be addressed by phone, or a home visit is in order. Phone consults are for information, not instruction. If the breastfeeding problem is beyond my area of expertise, referrals will be provided.

* Indicates required field

Name *

First

Last

Email *

Phone number *

What is the nature of your problem? What is your baby's name & date of birth? *

Please include 3 days/times that you are available for consultation. Once we decide on a mutual day, you will call me at the pre-arranged time. Please give 24 hours notice if you need to cancel or change time of appointment. *

Submit

Phone Consultation - 1 hour

50.00