Name
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First Name
Last Name
Type of Consultation
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May select more than one.
Email Address
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
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Significant Others Name
If pregnant, due date:
If delivered, baby's birthday:
Baby's Name
Birth Weight
Current Weight
Twins only: Baby #2 Name
Twins only: Baby #2 Birth Weight
Twins only: Baby #2 Current Weight
Did you have any complications during your pregnancy or delivery? Has your baby been healthy and gaining weight since delivery?
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Overview of your daily schedule (be as specific as possible).
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Feedings, Naps, Overnight
Where does your baby sleep?
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How are you feeding your baby?
If bottle feeding, what type of bottledo you use? If formula feeding, what type of formula do you use?
Do you use a pacifier? What brand?
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Do you use a swaddle? What brand?
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Do you use white noise? What brand?
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What are your top 3 questions/concerns/struggles/anxieties?
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Anything else I should know about your family that would effect your schedule? Jobs? Siblings? What makes your family/situation unique?
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Do you have a copy of the Moms on Call 0-6 or 6-15 Month book (depending on your baby's age)?
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How did you hear about Little Lambs?
Liability Release Statement
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Anytime that you are concerned about your baby or notice symptoms, call your 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 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 pediatrician’s visits or recommendations. This consultation is used as a supplement to your pediatrician’s recommendations. Use the information obtained as a guide for your own parenting choices.
If you are ever concerned that 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 state the name, age, and current weight of your child at the beginning of each e-mail.
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 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!
