I authorize the IBCLC to release the information gained during the consultation to my primary care physician(s), health care provider, and insurance company (to assist with claim reimbursement).
I authorize Creative Lactation staff to photograph myself and/or my baby for educational purposes. I understand that these photos or videos are not to be sold or released on the Internet.
I understand that all medical care for my baby and me is to be provided by our physician(s) and health care providers. I understand and agree that electronic communication (such as email and texting) is not secure. If I choose to share Protected Health Information, I accept the risk. I have read the privacy practices from the Creative Lactation website. A written copy will be provided on request. I understand and agree that the information in this file will be kept for a period of seven (7) years.
I accept payment responsibility for the breastfeeding consultation, and equipment rental or purchase, regardless of insurance or other third party involvement. I authorize the staff of Creative Lactation to charge my credit card for services rendered. The fee for service is as follows: $150.00 an hour (billed in increments of 15 minutes thereafter).