Patient Forms

This form acknowledges that you have access to and reviewed the following patient forms:

Notice of Privacy Practces for Protected Health Information (PHI)Patient Consent and Notice Acknowledgment FormPractice Letter Overview with Financial ProcedurePrenatal Practice Letter (if applicable)

By signing here, you are consenting to treatment for all visits beginning with your first visit with New England Mothers First.

First Name*

Last Name*

DOB*

Baby's First Name*

Baby's Last Name*

Baby's DOB*

Electronic Signature*

This is for Consent of Photography and Data Collection*:
SelectYesNo

(This is separate from signature for consent to treat) (If any photo is collected, it is discussed again prior to utlizing any pictures or video)

Disclaimer: This consent form includes all medical visits, beginning with the ini:al visit, with New England Mothers First

I acknowledge New England Mothers First is an independent nurse practitioner practice who specializes in expertise breast-feeding medicine. NEMF utilizes medical office billing in accordance with the Mother/Baby insurance plan design. New England Mothers First is not a Lactation Consultant company nor a free service.