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Consent for Lactation Consultation

I give my consent for the lactation consultant to work with my baby and me during this consultation for my feeding problem/concern. This consent is for face-to-face and virtual visits and all follow-up contacts; it includes phone conversations, and information sent via the Internet, fax, phone texts or regular mail.

I understand that a lactation consultation may involve:

  • Touching/Virtual assessment of my breasts and/or nipples for the purposes of assessment
  • Observing virtually or inserting gloved fingers into my baby’s mouth to assess suck and oral cavity
  • Observation of breastfeeding, 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 infant feeding.

I give my consent for the lactation consultant to contact my baby’s and my primary health care provider with a report of our consultation, as the ethics of her profession require, and to consult with them in any way she deems appropriate. I agree that she may discuss my case and forward my contact information to a breastfeeding support group counselor.

I give my consent for the lactation consultant to release pertinent information to my insurance company, as necessary.

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. My baby and I won’t be identified in any way, but aspects of our situation might be described and discussed

I give permission for photographs and recordings to be made, of both my baby and me, for charting and clinical education purposes.    If the photographs are shared in a clinical or educational context, identifying features or information will not be shown.

I understand that total payment is expected at the conclusion of the consultation. I will receive paperwork to submit to my insurance company for consideration of reimbursement if not in network.

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 Professional Conduct of the International Board of Lactation Consultant Examiners, the IBLCE Scope of Practice for IBCLCs, the Standards of Practice of the International Lactation Consultant Association, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

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