Dalaney Young, BS MCH, IBCLC   
 dalaney@newdaylactation.com
720-234-3643

Mother and Infant(s) Information

Please check any breastfeeding issues you are experiencing.
Low Supply
Oversupply
Cracked Nipples
Sore Nipples
Engorgement
Breast pain
Weight Gain Issues
Breast Pump Questions
Desire to Wean From Bottle
Sleepy Infant
Information on Infant #2 and/or Infant #3 if applicable.

Mother's Health History

Please check any that apply to the mother.
Infertility
PCOS
Reynaud's Syndrome
Gestational Diabetes
Type 1/2 Diabetes
Breast implants
Breast reduction
Chest Surgery
Nipple Piercing (past or present)
Drug Dependence
Alcohol Dependence
HIV Positive
Tobacco use

Current Child Delivery and Birth Information

Epidural
Vacuum
Forceps
Induction
Pitocin
IV use
Blood transfusion
VBAC
Please check any that apply in regard to the infant(s) either current or after birth.
Jaundice
Low Blood Sugar
Temperature Regulation Issues
Respiratory Issues

Payment Information

Please Note: Credit card information will not be charged prior to completion of appointment.  However, a $25.00 fee will be charged to your credit card if you cancel within 12 hours of your appointment time.
Visa
MasterCard
American Express
Discover