Registration Form | Oksana Laurin

Patient Intake Form

Infant's Name*
First Last
Infant's Gender*
- Male
- Female
Infant's OHIP number*
10 digit number and 2 letter version code:
Date of Birth*
Date Format: MM slash DD slash YYYY
Mother's Info
Name*
First Last
Mother's OHIP number*
10 digit number and 2 letter version code:
Address*
Street Address Address Line 2 City Province Postal Code
Medical History
1st week Breastfeeding experience*
Describe your breastfeeding experience in the 1st week:
Breastfeeding difficulties*
Please describe your current or most recent breastfeeding experience:
Are you currently under medical treatment?*
- Yes
- No
Medical Treatment*
Please describe any treatments:
Are you currently taking any medications?*
- Yes
- No
Medications*
Please list all medications you are currently taking:
Do you have any known allergies?*
- Yes
- No
Allergies*
Please list your Allergies:

Mother's Info