Consent for Breastfeeding Consultation Services

I grant my permission for breastfeeding consultation services to be performed by the staff of the Breastfeeding Lady, LLC. 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 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 Breastfeeding Lady LLC 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 Breastfeeding Lady, LLC to charge my credit card for services rendered. The fee for service is as follows: $175.00 an hour (billed in increments of 15 minutes thereafter).

Optional: During the consultation I would like my support person to photograph this session for my own personal use. I understand that these photos or videos are not to be sold or released on the internet. The lactation consultant agrees to be photographed or videoed for my personal teaching purposes only.
Optional: I authorize Breastfeeding Lady, LLC 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.
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Mother's Signature *
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