Forms

Forms

Consent for Lactation Consultation

The following is a consent form to make clear the limitations and responsibilities of the lactation consultant and the mother.

I hereby give my consent for Laurel Sproul, [International Board Certified Lactation Consultant [“IBCLC”] of Mother’s Milk for Baby’s Health, to offer professional services with respect to my child/baby and me for a consultation regarding my breastfeeding problem/concern. This consent shall cover all in-person, face-to-face visits and all follow-up contacts; it shall also include phone conversations, and information sent via the Internet, fax, email, or regular mail pursuant to the described parameters and actions detailed more fully below.

I understand that Laurel Sproul is a certified IBCLC and will provide care as an IBCLC.

I understand that a lactation consultation may involve the following assessment and/or treatment services, including but not limited to:

  • touching my breasts and/or nipples for the purposes of assessment;
  • inserting gloved fingers into my baby’s mouth to assess suck and oral cavity;
  • 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 Laurel Sproul, IBCLC, to contact my baby’s and my health care provider(s) 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 give my consent for Laurel Sproul, IBCLC, to release pertinent information to my insurance company, as necessary.

I give my consent for Laurel Sproul, IBCLC, to use clinical information obtained during our sessions for education of other health care providers and other mothers/clients about lactation. I understand that my baby and I will not be identified in any way, but that details and/or other aspects of our situation might be described and discussed.

I agree and consent to allowing Laurel Sproul to discuss my case with, and forward my contact information to a breastfeeding support group counselor, Midwife, or my doula, if I have one.

I give permission for photographs and audio and/or visual 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 agree to have communications about my case be sent by email/text. I understand that this is not a secure or  encrypted means of communication, and the materials may contain protected health information [PHI].

I understand that total payment is expected at the TIME OF the consultation. I will receive paperwork to submit to my insurance company for consideration of reimbursement.

I understand that for this lactation consultation and all follow-up, Laurel Sproul, IBCLC, 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).

I have received a copy of the Notice of Privacy Practices of the lactation consultant.

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If Mom agrees (consents), signature here and date

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