Name
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First Name
Last Name
Significant Other's Name
First Name
Last Name
Email Address
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Type of Consult
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In-Home- $350
Zoom- $250
Phone- $250
Due Date
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Hospital where you plan to deliver:
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OBGYN/Midwife Name
Are you planning for a vaginal delivery or c-section?
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Are you planning to breastfeed or formula feed?
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What is your plan for pain management during labor?
Select all that apply
What are your top 3-5 questions, concerns, or worries?
Anything special I should know about you, your family, or past experience?
Liability Release
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Anytime that you are concerned about you or your baby or notice symptoms, call your OBGYN or pediatrician’s office. This consult and book/dvd are designed to provide information on the care of babies. It is intended as reference material only, not as a medical manual. This consult is done with the knowledge that Little Lambs, LLC or Moms On Call, LLC specifically disclaim all responsibility for any liability, loss, or risk-personal or otherwise-to any parent, person, or entity with respect to any illness, disability, injury, loss, or damage to be caused, or alleged to be caused, directly or indirectly, by the use or application of any of the contents of this consultation.
This consultation does not take the place of your OBGYN or pediatrician’s visits or recommendations. This consultation is used as a supplement to your OBGYN & pediatrician’s recommendations. Use the information obtained as a guide for your own parenting choices.
If you are ever concerned that you or your child may be experiencing a medical emergency, please call your pediatrician or 911 right away.
Individual results may vary based on methods and consistency implemented by caregivers.
All fees will be clear and agreed upon prior to any service being rendered.
1. Please begin each email with your name & number of weeks you are into pregnancy -or- your baby's name and age.
2. State your questions in bullet point format, as this will help ensure I answer your exact questions
3. Be as specific as possible with your current routine and schedule.
4. I typically respond in less than 24hrs, and guarantee a response in less than 48 hrs.
5. If you encounter a problem that you feel requires a response in less than 24hrs, this is typically a good indication that your pediatrician/OB should be notified.
6. While I do work on the weekends, routine inquiries received on Saturday-Sunday, that do not require immediate attention, will be responded to on Monday.
7. If I am going to experience a temporary change in my schedule (such as vacation, family illness), which could affect my ability to respond to my current clients in my typical fashion, I will let you know.
As always, I consider it such an honor to be asked to serve and support your family in this way!
eSignature
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