Lactation Services Consent Form

• I give my consent for the Lactation Specialist to work with me and my baby during this consultation for my breastfeeding problem/concern. This consent is for in person visits, as well as phone conversations.
• I understand that a lactation consultation may involve:
  • 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 and use of equipment or supplies that may be recommended
  • Demonstration of techniques designed to improve breastfeeding
• I understand a partial or follow-up visit is sometimes necessary.
• I understand that breastfeeding supplies and/or breast pumps may be recommended as effective management of specific situations
• I understand that I am responsible for informing the Lactation Specialist of changes I feel are necessary in the care path at the time of the visit or during follow-up communications. I understand it is my responsibility to call the Lactation Specialist with progress reports, questions, or concerns.
• I give my consent for the Lactation Specialist to use clinical information and any photographs obtained during our sessions for conferring with other health care providers and education of mothers about lactation. I won’t be identified in any way, but aspects of my situation may be described and discussed.
• I understand that the Bloomington Pediatrics’ financial policy I signed also applies to Lactation services, including any copay, deductible or co-insurance assigned by my personal insurance policy for the services rendered.
• I understand that for this lactation consultation and all follow-ups, the Lactation Specialist will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners, and the Standards of Practice of the International Lactation Consultant Association.
• I have been offered a copy of Bloomington Pediatrics’ Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.