Patient Request Form

First Name

Last Name

Phone Number

Email Address

Street Address

City

State

Zip Code

Baby's Due Date/Date of Birth

Main Concerns

Please list any questions you have

💲Home Visit Travel Fees are $70 and not covered by insurance.

🚨Virtual visits not covered by: UHSS, UMR, GEHA, UHC, BCBS Federal, and Cigna Allegiance.

⚠️ Our Katy office usually has very limited availability or may not be accepting new patients.

Would you be open to other locations if it means being seen sooner?

Yes

No (I prefer my selected location only)

Preferred Days or Times

💲Classes are not covered by insurance and prepayment is required at time of booking.

Additional questions or information

General Consents (Required)

By signing below, I have reviewed and agree to each of the following Bayou City Breastfeeding documents at the version shown. The General Consent contains the consumer disclosures required for electronic records and signatures. The Notice of Privacy Practices contains the Texas Health & Safety Code §181.154 notice on electronic disclosure of protected health information. I may request a paper or emailed copy of any document at any time at no charge.

• General Consent v2026..1

• Notice of Privacy Practices v2026.1

• Good Faith Estimate / Surprise Billing Notice v2026.1

• Payment-Related Consent v2026.1

I understand that visit-specific consents (lactation, chiropractic, therapeutic laser, home visit) and the optional HIPAA Marketing Authorization will be presented separately when they apply to me.

I agree to the BCB Payment Policies and General Consent

Full Name for Signature (REQUIRED)

✏️ By typing your full name in the signature field above, you are providing your digital signature and agree to the consents and acknowledgments. Your digital signature has the same legal effect as a handwritten signature.

Thank you for taking the time to tell us more about your needs.

We’re honored to be part of your journey and are dedicated to providing the care, encouragement, and support you deserve. 💗

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