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Information/Permission Form

Each client signs a form before we begin the consultation, which includes the following permissions:

  • I give my consent for the lactation consultant to work with my baby and me during this consultation for my breastfeeding problem/concern.  This consent is for visits, phone conversations, and information sent by e-mail, fax or regular mail, and includes appropriate follow-up contacts.

  • I understand that time that the initial consultation will average 1-2 hours.  Once the visit reaches two hours, a follow-up visit is recommend to address any remaining issues.

  • Payment in full is expected at the time of service unless prior arrangements have been made.

  • I will receive a receipt to submit to my insurance company for consideration of reimbursement.

  • I understand that a lactation consultation may include touching my breasts and/or nipples for the purposes of assessment; inserting gloved fingers into my baby’s mouth to assess suck; observation of a breastfeed, and suggestions to enhance latch or position; demonstration of the use of equipment or supplies that may be recommended; and demonstration of techniques designed to improve breastfeeding.

  • I give my consent for the lactation consultant to use clinical information obtained during our sessions for education of other health care providers and mothers about lactation.  I won’t be identified in any way, but aspects of my situation might be described and discussed.

  • I give my consent for the lactation consultant to contact my baby’s and my primary health care provider, as the ethics of her profession require, and to consult with them in any way she deems appropriate.  I understand that all medical care is to be provided by my own physician(s).

  • I understand that for this lactation consultation and all follow-up, the lactation consultant will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners, the Standards of Practice of the International Lactation Consultant Association, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  

  • I understand that communication via email and text are not considered HIPAA-compliant but will be kept confidential.

  • I understand that follow-up care by phone and/or email will continue for 1-2 weeks following the consultation.  I am encouraged to provide frequent updates to the lactation consultant during this time for best results.  If I require additional help after two weeks, a follow-up consultation is recommended.

Notice of Privacy Practices
Your privacy is very important to me, which is why I never share your information with anyone other than your healthcare provider team.  Following the Health Insurance Portability and Accountability Act of 1996, here is my company's Notice of Privacy Practices:  
Cancellation Policy
Helping mothers as quickly as possible is as important to me as it is to the mothers who request my assistance.  Try to keep your scheduled appointment, as I may have turned away other families needing help. The exceptions are cases of illness, exposure to illness or a true emergency.
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