Consent for Breastfeeding Consult Services
I grant my permission for breastfeeding consultation services to be performed by the staff of the Creative Lactation. I understand that to learn how the breastfeeding consultant can help me, this consultation may consist of the following: a medical history of my baby and me, a physical assessment which may include touching mother, an assessment of how my baby breastfeeds including an examination of his/her mouth and suck (offering a gloved finger for baby to suck on), the use of breastfeeding aids and equipment, including pre- and post-feed weight to measure milk transfer, accurate to 1/10th of an ounce, helpful hints and other educational information based on my unique situation, to help achieve our breastfeeding goals.

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).

I understand that typing my name constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Consent.: *
Your answer
On occasion Jessica Sypolt of Creative Lactation may have an intern who will attend a consultation.
Submit
Never submit passwords through Google Forms.
This form was created inside of creativelactation.com. Report Abuse - Terms of Service