Referral Script Pads

Our Referral Script Pad form is available in two formats, Fillable and Printable.  The format that's best for your practice depends on whether the providers in your area tend to use mostly paperless electronic charting and file systems or old-school hardcopy paper charting and files.  Some provider offices may appreciate having both formats!

Fillable Referral Script Form—Best for Paperless Offices

LactForms Fillable Referral Form

The Fillable version is a PDF file displaying a single image of the Referral Script Form with fillable fields that the provider can easily send to their patient electronically.  Pre-loaded flash drives are an easy way to give the file to provider offices if they don't have an email address or any other way to send it to them.  Just purchase flash drives in bulk (1GB or cheapest size) and copy the file onto each drive.  A fancy idea is to use flash drives with your logo imprinted

Printable Referral Script Form—Best for Hardcopy Paper Offices

LactForms Referral Pads

The Printable version is a PDF file intended for hardcopy professional printing as tear-off notepads (top edge glued with a cardboard backer) or sticky notes.  Formatted to look like a prescription pad, your practice information is in a header at the top with space below for the checking both parent and child issues.  Providers find printed notepads and sticky pads convenient way to refer their patients to you for lactation services.  They just check off a few boxes, tear off the page, and hand it right to the patient, who then has it handy as a reminder to make an appointment with you right away.   

Two printable PDF file versions are provided: 

  1. One 4.25" x 5.5" (10.8cm x 14cm) image*
  2. Four images on one 8.5" x 11" (21.6cm x 28cm)* page (some printing companies prefer four images that on a standard size page that's later cut into four parts)  

Custom printing services for both notepads and sticky notes are available at many places online.  Here's a few links for custom notepads (most can also make custom sticky notes):

I used to have my referral pads made at my local Staples Copy and Print Center after submitting the order online, but now the only options I can find on their site have the glue on the wrong edge (short end side instead of the top long end).  They can definitely make them, but you may have to go to your local Staples Copy and Print Center in person and explain what you need.  

Print Specifications

  • Custom notepads or sticky notes
  • 4.25" x 5.5" *
  • Notepads: one glued edge on long (5.5") side (top of landscape-oriented image) with cardboard backing
  • Sticky notes:  sticky area onlong (5.5") side (top of landscape-oriented image) 
  • 25-50 pages (25 is probably best for most Provider offices)
  • Ink:  2-3 color or greyscale printing (color catches the eye better but greyscale is less expensive)
  • Background can be any color including plain white

Header Options

Our Referral Script form looks more professional with the HeaderBox option showing your branding colors and logo.  But the HeaderFields option works just fine, too.  Learn more about our header options

Feedback Welcome

I'd love your feedback about how well this works for your practice.  And of course always feel free to reach out to me with any questions or other marketing ideas!

* If you prefer a different size (or need to fit European size pages), most printing companies can adjust the image.  But if they require a different image size, I'll be happy to provide it at no extra charge, just let me know!