International Breastfeeding Centre

REFERRAL FORM

Referral Date
Referral Date
Baby's Name *
Baby's Name
DOB
DOB
Baby's biological sex
Address
Address
Phone Number
Phone Number
Address
Address
Phone Number
Phone Number
Fax Number
Fax Number

Note:

  • Referrals can only be made by Medical Doctors, Midwives or Nurse Practitioners

  • Incomplete referrals will be returned to your office

  • Appointment request must be submitted by patients at www.ibconline.ca