Lactation Consultation Forms Customization 


Thanks for ordering your forms with the customization option!  Here’s the three-step process for making your customized forms:

STEP 1: (that’s where you are now)  Enter the information that you would like to appear on your form(s) on the form below.  When you click “submit,” the information will be emailed to me.

(Note:  If you’re in the US, you’ll need an NPI number to be recognized as a valid health care provider by insurance companies. Be sure to use these codes on your application:  174N00000X for non-RN IBCLC and 163WL0100X for RN IBCLC.)

STEP 2:  Within one week (or sooner if you purchased the expedited option), a “header” image with this information will be created and emailed to you for your review, proofreading, edits, and approval. (The email may come from me or my assistant, Melissa Preitauer.)

STEP 3:  Once you’ve given your blessing that the header is correct and the way that you want it, it will be applied to your customized form(s). Then, an email will be sent to you (from me or Melissa) with a non-expiring link to a Dropbox folder containing them for you to access directly or download.

Free free to contact me if you have any questions or concerns about this process.

Let’s get started on STEP 1 to enter your information!
Leave any fields blank that you don’t want to include.  And let me know if there’s something you would like to add that isn’t here.

New forms or upgrading/changing previous purchase?*

Name and Credentials

Your name:*
Degree(s) and/or credential(s) in the order to be listed after name:
Do you have a second practioner to include on the header?
Practioner 2's name:
Practioner 2's degree(s) and/or credential(s) :
Do you have a third practioner to include on the header?
Practioner 3's name:
Practioner 3's degree(s) and/or credential(s):
Do you have a fourth practioner to include on the header?
Practioner 4's name:
Practioner 4's degree(s) and/or credential(s):

If there are any other practioners to include, please submit their info under "Anything Else" below.

Company Name

Do you have a company name that you would like to include on the header?
Company name:
Do you use a special font for the company name?:
Font name:
If the font is unusual and you have the file, *please* upload it here:

Every effort will be made to match your preferred company name font, but if you don't have the file and it can't be found easily and at no cost, a close substitution can be made.  You may also purchase the file and send it to me.

Contact Info

Enter ONLY the info that you want included on the header.  

Address (If in the US, be sure to include the state):
Email:
Business phone (enter country code or area code in the first space):
-
Website:

Numbers

Enter ONLY the numbers you want to appear on your custom header. The more there are, the "busier" and more crowded your header will be. The most essential numbers are the tax ID number and the primary healthcare provider registration number.

Company tax ID number:
Primary healthcare provider registry number (NPI, APN, etc.):
Primary healthcare provider registry type:
Other healthcare provider registry number:
Other healthcare provider registry type:
IBCLC credential number:
Practioner 2's primary healthcare provider registry number (NPI, APN, etc.):
Practioner 2's primary healthcare provider registry type:
Practioner 2's other healthcare provider registry number:
Practioner 2's other healthcare provider registry type:
Practioner 2's IBCLC credential number:
Practioner 3's primary healthcare provider registry number (NPI, APN, etc.):
Practioner 3's primary healthcare provider registry type:
Practioner 3's other healthcare provider registry number:
Practioner 3's other healthcare provider registry type:
Practioner 3's IBCLC credential number:
Practioner 4's primary healthcare provider registry number (NPI, APN, etc.):
Practioner 4's primary healthcare provider registry type:
Practioner 4's other healthcare provider registry number:
Practioner 4's other healthcare provider registry type:
Practioner 4's IBCLC credential number:

Logo

Do you have a logo that you'd like to include on your forms?
Should the logo be in color on the form(s)? (Downside--may not copy well, Upside--more appealing.)
Upload logo:

If you get an error that it's too large, just email it to me directly at diana@dianawest.com.

Anything Else?

Any other info to include:
Just to make sure you're real:

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