Request a Consult

REQUEST A CONSULT

Please complete the form to confirm the insurance plans we collaborate with for your lactation consultations.

Phone Number 480-618-7219

Fax Number 480-885-2402

hello@originalmami.com

This form is HIPAA compliant

PATIENT INFORMATION

To get started, please fill out the following contact form. This will allow us to take the next steps in setting up your service request.

Full Name*

Your Date of Birth*

Phone*

Email*

Address Line 1*

Please include your street address and city

Baby's Full Name

Estimated Due Date or Infant Birth Date*

Please provide a brief description of what you need help with: *

Are you interested in any of the following Black Friday deals? *

A20% off Initial Consult (Self Pay)

BTravel Fee Waived for Insured Home Visit

C30- Min Lactation Massage - Add On $50

DN/A

What Insurance does the mother have? *

Both mother and baby are billed for lactation visits

ASelf Pay

BTriWest

CFirst Health Network

DBlue Cross of AZ

EAll other Blue Cross / Anthem Insurances

FAetna

GUnited / UMR / GEHA

HCigna

IMultiplan or PNOA Network

JOther Insurance

Does baby have/will have a different insurance than the mother? *

AYes

BNo

Cigna patients:

Are you eligible for lactation visits with Wildflower? If you have Cigna you may be eligible for up front insurance coverage for lactation visits.

ADoes not apply to me.

BYes, I was approved!

CNo, I was denied.

D I am already waiting to hear back.

ENo, thank you.

FI will do this right now!

Wildflower Link

Please use this link if you would like to request coverage. This form must be submitted AND approved prior to your visit for coverage.

https://portal.wildflowerhealth.net/affiliate-care/55fd719

How Did You Hear About Us?*

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