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1609 E Greyhound Pass Carmel, Indiana 46032
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Feeding Plan
Prior to admission, a feeding plan shall be established and written for each infant (age 6 weeks - 12 months) in consultation with the parents and based on the written recommendation of the child's pediatrician or family physician. Feeding plans must be continually updated by physician or parent. [470 IAC 3-4.7 (b)]
The following feeding plan has been recommended for this child.
Name of child
(Required)
First
Last
Date of birth
(Required)
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Month
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12
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Day
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Age in Months
(Required)
Time to Feed
(Required)
Formula / Food Item and Amount
(Required)
Special Instructions
Signature of Parent or Physician
(Required)
Date of Parent or Physician
(Required)
MM slash DD slash YYYY
Age in Months
Time to Feed
Formula / Food Item and Amount
Special Instructions
Signature of Parent or Physician
Date of Parent or Physician
MM slash DD slash YYYY
Age in Months
Time to Feed
Formula / Food Item and Amount
Special Instructions
Signature of Parent or Physician
Date of Parent or Physician
MM slash DD slash YYYY
Age in Months
Time to Feed
Formula / Food Item and Amount
Special Instructions
Signature of Parent or Physician
Date of Parent or Physician
MM slash DD slash YYYY
Signature of physician / nurse practitioner
(Required)
Date signed
(Required)
MM slash DD slash YYYY
BRANFORD –
203-488-5437
CHESHIRE –
203-271-1147
WALLINGFORD –
203-269-5437