Physician Referral Form

Mahinaona Pediatrics LLC -

A Breastfeeding Center

3465 Waialae Ave, STE 270, Honolulu, HI 96816

PH: 808-737-4675  Fax:  808-737-4978

Referral for Lactation Consultation

Name of Physician Referring:_____________________________________________

Physician Phone: __________________________  Physician Fax: _______________

Reason for referral (check all that apply):

___ Neonatal difficulty feeding at the breast (P92.5)

___ Ankyloglossia (Q38.1)

___ Congenital malformation of palate (Q38.5)

___ Underfeeding of newborn (P92.3)

___ Slow feeding of newborn (P92.2)

___ Abnormal weight loss (R63.5)

___ Excessive crying of infant (R68.11)

___ Fussy infant (R68.12)

Patient’s name _____________________________________  DOB: ___________

Patient’s birth weight ______________________ Current weight: _______________

If patient was born somewhere other than Queen’s Medical Center or Kapiolani Medical Center, please fax discharge summary.

By filling out this form, the referring physician is indicating an agreement for this referral to remain in effect as long as a woman continues to breastfeed and requires lactation support.