Virtual Breastfeeding Brunch Consent form
Breastfeeding Brunch is a weekly virtual support group happening every Wednesday @11:45am PST via "google meet". You will receive the link within 24
 hours of signing the consent. If you're using a phone to access, you will need to download the Google meet app, there's no need to create an account.
You only need to sign this consent once, and the link provided will work every week :)
Sign in to Google to save your progress. Learn more
Email *
Email address *
Name *
Baby's name/ age
Today's Date *
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DD
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YYYY
How did you hear about this group?
Are you also interested in being added to the in-person meetup invite? (This is currently a monthly meetup in Thousand Oaks, CA. You would be added to a separate calendar invite if you are interested)
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I understand that the “Breastfeeding Brunch” is meant to provide me with information and education. Participation in this group does not create a clinical relationship between me and Samar Mroue, RN, IBCLC. *
Required
I understand that I am responsible to consult with my primary care provider and/or my baby’s primary care provider before taking action on anything that happens here today. I recognize that Samar Mroue, RN, IBCLC is not a medical doctor and cannot provide medical advice or supervision. *
Required
 I recognize that if I have an established clinical relationship with Samar as my lactation consultant, it is up to me what I wish to share in the group setting about our prior clinical relationship. If I do reveal a clinical relationship, I understand that Samar will not make reference to our private clinical conversations in the group context; and will not provide me with specific or personal clinical recommendations or a plan of care. *
Required
*IBCLC Students Only* If you are an observing student, Please let me know here what date you would like to attend Breastfeeding Brunch. Also please print your name in this section as an acknowledgement that you have read and understood the confidentiality agreement found on this link https://drive.google.com/file/d/1AEHlmE0G8UqNb4dOcwxl1rTDzj8_1anF/view?usp=sharing 
Your printed name below will be considered your virtual signature *
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