Lactation Support Request -Referrals Closed at the Moment | Semiahmoo Bay Midwives

Lactation Support Request

Doctors/Midwives: download PDF of form here

We are currently overwhelmed by requests and not able to accommodate new patients at this time. We appreciate your ongoing support, and will open this page back up when able.

Are you a current patient of Semiahmoo Midwives?*

Have your provider fill this out if you are not a current patient. Referrer Name & MSP #:*

We will need a midwife or doctor's referral/billing number in order to care for you if you are not already a patient of our practice. Thank you!

Name (As appears on Care Card)*

Date of Birth*

Care Card Number*

Email address:

Phone Number:

What stage of pregnancy are you currently at?*

Newborn Date of Birth

Feel free to elaborate on why you are seeking a lactation consultation.

File Upload Referral Letter/Note