Consultation Consent Form
Email address *
Read and sign before consultation:
I understand that all medical care is provided by my physician and that any change in care/recommendations needs to be discussed with the physician.

I grant permission for to Rachel to share her assessment and information shared in my consult to my and my infants healthcare team. Including doctors, other lactation consultants. Rachel uses fax, phone, and HIPAA compliant email for communication to providers.

I grant permission for information/photography/video from this consultation to be used to further the knowledge of breastfeeding, with the understanding that no PIH or identifying features will be used. I give permission for Riverside Lactation to use photos for case studies, power points, research, and to send in my clinical notes to mine and my infants physicians and specialists.

I understand the Lactation Consultant, Rachel Blumberg's scope of practice when evaluating for oral restrictions, mastitis, or any other medical condition is to educate, assess & refer to the appropriate healthcare provider. Diagnosis of medical issues is left to the medical professional.

I understand that a lactation consultation by Rachel Blumberg, International Board Certified Lactation Consultant may include a visual & manual assessment of the mother's breasts, baby's mouth, body, and suck to the breastfeeding situation. Demonstration of techniques for improving breastfeeding, use of breastfeeding equipment, and recommendation of a feeding plan to resolve breastfeeding issues, which may be adjusted during the course of care.

I understand that I (the client) am responsible for informing Rachel Blumberg of any relevant information or changes that affect my breastfeeding situation. I understand that it is my responsibility to call or email Rachel Blumberg with progress reports, questions or concerns.

I understand that the payment for the lactation consultation and any necessary breastfeeding equipment are my sole responsibility and expected at the time of service.

There is a $100 cancellation fee if you cancel within 24 hours of your appointment.

Communication: Text is not HIPAA compliant, email and phone calls are my only way of communication at this time.

Please print a personal copy.

By electronically signing below I understand the conditions set forth above: Please Sign and Date:

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