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Imprint | Data protection

Deutsch
Home Page
About me
Prices
Contact form
Imprint | Data protection

Contact form

Dear Parents,

I am happy to offer you personalized breastfeeding support. To help me assist you in the best possible way, please fill out my below contact form.

Name und Surname of the mother *

Street and house number *

Zip code *

City

E-Mail-adress *

Phone number *

Name and surname of the child *

Sex of the child *

Male

Female

Birth *

Vaginal

C-section

Breech birth

Facial presentation

Kristeller manouver

Vacuum extraction birth

Forceps

Umbilical cord around the neck

Received IV fluids during birth

Date of birth *

Weight of birth in Gramm *

Week of pregnancy at birth

Last weight in Gramm

Date of weight measurement

If applicable, how much formula do you approximately feed in 24h?

Summary of the issue *

Opinion of the doctor

Opinion of the midwife

Pre-existing conditions/acute illness of the mother

Medication of the mother, for example contraceptive, since when?

Breast sugery

Augmentation

Reduction

Breast lifting

Pre-existing conditions/acute illness of the child

Medication of the child

Number of siblings of your baby

Maximum time of breastfeeding per child (in weeks, months, years)

I would like on a private bill *

a home visit starting from 80 €, see prices

a telephone consultation starting from 10 €, see prices

The visitor of your website has agreed to the clause with the following text *

I hereby agree that the data I have entered in the contact form may be stored electronically and processed and used for the purpose of contacting me and providing breastfeeding consultation. I am aware of the information regarding data protection, the use of my data, and my rights according to the Berlin Data Protection Act and Articles 15-17 of the DSGVO. I understand that I can revoke my consent at any time.

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