The Newman Breastfeeding Clinic requires a referral form for the breastfeeding parent and/or each breastfeeding parent- if you will be co-breastfeeding. Referrals from either a doctor or midwife or nurse practitioner are acceptable. Prenatal appointments can be made for any breastfeeding concern including induced lactation for adoption, surrogacy or co-breastfeeding, starting breastfeeding out right, previous breast surgery and so forth.  We are happy to help support you to breastfeed.


Breastfeeding Parent's

Breastfeeding Parent First Name (required)

Breastfeeding Parent Last Name (required)

Breastfeeding Parent's Health Card # [ten digits] (required)

Breastfeeding Parent's Health Card VERSION CODE [two letters] If no version code, LEAVE BLANK.

Breastfeedingparent Email (required)

**If there are two breastfeeding parents please enter the first and last name as well as health card information for the second breastfeeding parent in the Main Concerns box below**

My Main Concerns Are... [max 300 characters] (required)

 I confirm that I have read and understood all information included on this page

An email will be sent to you within 24 business hours