Book a Prenatal Appointment – International BreastFeeding Centre

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. Please print and have your health care provider complete the referral form and email attached to clinic@ibconline.ca, upload form in the appointment request below or have your health care provider fax referral to 416-498-0012. https://ibconline.ca/wp-content/uploads/2018/06/Referral-Form-Mother.pdf

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Parent Information

Breastfeeding Parent's Full Name*

First Last

Pharmacy Name*

Pharmacy Fax Number*

Date of Birth*

Is this a virtual appointment request?*

Yes

Most prenatal appointments can be done via virtual appointment option.

Do you have an Ontario Health Card?*

Yes

If you are a NON-OHIP patient, there will be separate charges. Please contact clinic@ibconline.ca to register

Health Card Number*

Health Card VERSION CODE [two letters]*

If no version code, enter NONE

Address

Street Address Address Line 2 City Province Postal Code

Phone*

Mobile Phone(for text appointment reminders)

Email*

Enter Email Confirm Email

Parent Referral

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 5 MB.

My Main Concerns Are...*

Appointment Fee

Price:

For more information email clinic@ibconline.ca or call 416-498-0002 ext. 221.