Follow Up Postpartum

Your First Name & Last Initial(required)

Your Email Address(required)

Your Phone Number(required)

By checking this box, you are giving permission for the Breastfeeding Buddies Program to receive this form via email and use your email address and/or phone number to communicate with you. While all precautions are taken to ensure security and privacy, email can be vulnerable to misuse. Please do not include any confidential health information on this form.

What are your Pronouns? check one or more options for the set of pronouns you want people to use when they refer to you
---She/HerThey/ThemZe/HirXe/XirHe/HimSomething Else

Your Baby's Birthdate

We want to know who we're reaching! Please select the region where you live:
Waterloo RegionGuelph-WellingtonLambtonGTAHamilton/NiagaraOttawa/Northern OntarioOther

Where did you hear about our services? MidwifeObstetricianDoctor/NurseGrand River HospitalCambridge Memorial HospitalSanctuaryCarizonCAWAPublic Health Breastfeeding ClinicKitchener Downtown CHCNorth/West Lambton CHCGuelph CHCMy Breastfeeding BuddySocial MediaWeb SearchFriend/FamilyOther

What is the language spoken most frequently in your home? EnglishOther (please list below)

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