Honey. Infant Feeding Clinic Appointment Request

Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Lactating Parent's Date of Birth *

MM

DD

YYYY

Has your baby arrived yet? *

Yes

No

If so, baby's date of birth

MM

DD

YYYY

Tell us all the things... *

We support mamas on their breast, bottle formula, pumping, prenatal, postpartum, back-to-work, weaning, feeding journey. Help us help you by telling us what is leading you to seek infant feeding support at this time. This form is confidential and will only be used to make certain we match you with the best Honey professional and provide the best possible care. We may suggest additional support based on what you share.

Prenatal infant feeding education

Breastfeeding (supply, latching, general questions)

Bottle refusal

Pumping

Possible oral (tongue, cheek, lip) ties or restrictions

Preferred appointment location

*Limited amount of in-home visits available*

Honey Clinic (Ferndale)

Virtual

In-Home (within 15 miles of Ferndale)

First Available

Schedule *

Please indicate all day/time blocks you are available for us to schedule your appointment.

Mondays 9a-12p

Mondays 12p-4p

Tuesdays 9a-12p

Tuesdays 12p-4p

Wednesdays 9a-12p

Wednesdays 12p-4p

Thursdays 9a-12p

Thursdays 12p-4p

Fridays 9a-12p

Fridays 12p-4p

How soon would you like to be seen? *

First Available

Within 24-48 hours

Within 3-4 days

Within a week

Have you ever or do you currently receive services at Honey?

Yes

No