Request an Appointment | Register for Class | Self Pay - Bayou City Breastfeeding

This form is used for Health Share Plans, Out of Network Plans and Self-Pay clients
Visits are self-pay if we are not in-network with your insurance.
We can provide a superbill for potential reimbursement.
For pricing, visit: Cash Pay Price List

Step 1: Let's Learn About You

Briefly describe your situation for us:

Contact Information

Gestational or Lactating Parent's Name

Legal Name (First and Last) (REQUIRED)

Email (REQUIRED)

Mobile Phone Number (REQUIRED)

Street Address:

City:

State:

ZIP (REQUIRED)

Lactating Parent Date of Birth:

General Information

Class Registration

We do not accept insurance for our classes

Which class(es) do you want to register for? Please include you preferred class date:

Breastfeeding Blueprint Online class: $45 per person

Thursday, June 4th, 6:30-8:30 PM CT
Thursday, July 9th, 6:30-8:30 PM CT

Breast Pump Puzzle Class (In person in our Houston office): $45 per person

Saturday, June 27th, 10:00 AM - 11:30 AM CT
Saturday, July 18th, 10:00 AM - 11:30 AM CT

Push it Real Good: Prepared Childbirth Class: $250 per couple, limit 3 couples

Saturday, June 20th, 09:00 AM–4:00 PM · In-Person · Houston
Saturday, July 11th, 9:00 AM–4:00 PM · In-Person · Houston
Saturday, August 29th, 9:00 AM–4:00 PM · In-Person · Houston
Saturday, October 3rd, 9:00 AM–4:00 PM · In-Person · Houston

Visit Information

Urgent Visit Notice:

For urgent concerns, we offer a virtual triage visit and can usually schedule within 72 hours.

Preferred days/times:

Any days/times that do NOT work?

Step 4: Tell us about your baby

Baby First Name :

Baby A First Name:

Baby B First Name:

Baby C First Name:

Baby's Last Name:

Baby's Date of Birth (REQUIRED)

Baby's Due Date (REQUIRED)

Optional — Stay Connected

Submit your information

CONSENTS (ALL ARE REQUIRED FIELDS)

Self-Pay Consent (REQUIRED)*

I understand that I will be responsible for payment for my visit. I also understand that I will have a $100 deposit for my first visit.

Consent for Prenatal Classes (Required)*

I understand that all prenatal classes are self-pay and that insurance will not be accepted as payment for the class. I agree to have my card on file charged for the full cost of the class I am registering for.

General Consents (REQUIRED)*

✍️ By typing your full name in the signature field below, you are providing your digital signature. This has the same legal effect as a handwritten signature.

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)

Your information will be encrypted.

Request an Appointment | Register for Class | Self Pay