Step 2

STEP 2:

To register for flexible online scheduling, please complete the form below.

* Indicates required field

Your Name *

First

Last

Phone Number *

Permission to send appointment confirmation texts to this number? *

Yes No

Email *

Patient Name *

First

Last

Patient's Date of Birth *

Reason for the Appointment *

I understand that my confirmation email may be directed to my spam folder unless I enter Mary@WNYOrofacial to my contact list. I will ensure to check my spam folder for my confirmation email if I am concerned that I have not yet heard back. *

I understand

I understand that I may have a visiting professional present to shadow my IBCLC or a supervised apprentice IBCLC participating in my appointment. I acknowledge that I have the right to refuse any visiting provider in the room. *

I understand

I understand that complex feeding challenges commonly take time to resolve, that revisions to my Individualized Care Plan are commonly appropriate and necessary and that frequent communication of concerns, questions, and progress between me and my IBCLC facilitate the best likelihood of success in achieving my goals. To that end, I am responsible for informing my IBCLC of any relevant information or changes that may affect my, my child, or my baby's status as soon as possible. *

I understand

How did you hear about us? *

Please click the button below to proceed to step 3 of your initial assessment request process.

Proceed to Step 3