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

 

Breastfeeding Parent's

Breastfeeding Parent First Name (required)

Breastfeeding Parent Last Name (required)

Breastfeeding Parent's Date of Birth (required)

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

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

Address

Apt, Street Number, Street Name

City

Province

Postal Code

Phone (required)

Mobile Phone (for text appointment reminders)

Breastfeedingparent Email (required)

Parent Referral

My Main Concerns Are... [max 300 characters]

I confirm that I understood an email reply to this appointment request will be sent within one business hour of receiving the referrals. ***If you do not find this email message in your inbox please check your junk or spam folder.



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