EPIC Breastfeeding Request Form

Please provide us with the following information to ensure necessary arrangements (training team, delivering of materials, etc.) are made. Our office will contact you as soon as possible to confirm the date of your presentation.

Thank you and we look forward to providing you with this educational opportunity.

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* 1. Select which topic(s) you want presented:

Breastfeeding Fundamentals - 1 hr.

Advanced Breastfeeding Support - 1 hr.

Supporting Breastfeeding in Hospital - 1 hr

Question Title

* 2. If you selected multiple topics above, please choose one of the following:

I want all topics presented on one date. (Allow 1 hr per topic.)

I want each topic presented on different dates.

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* 3. Who is requesting this program?

Name & Title:

Email Address:

Office Number:

Question Title

* 4. What is the name of your Practice/Facility?

Organization Name :

Street Address: (include city and zip)

County:

Health District:

Location Contact: (if different from person requesting)