CONSENT FOR PHONE CONSULT
Chicago Lactation Consultants
I give consent for Laura Coulter, CNM, MS, IBCLC to discuss my breastfeeding problem with me by phone or Skype and to offer suggestions for symptom management only. I understand that this is limited and cannot be considered a comprehensive evaluation and assessment. *
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The information I have provided to Laura is accurate. *
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I agree to receiving information and handouts by text or email. *
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I have reviewed the HIPPA statement provided at www.chicagolactationconsultants.com *
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Mother's name: (This serves as your signature) *
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Your phone number: *
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Your email address: *
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