I give my written consent to Heather Martin,IBCLC,RLC- Beyond the Breast Lactation Services to address my current breastfeeding concerns during this and subsequent consultations.

I understand that the consult may include but is not limited to a visual and physical assessment of my breasts, my infant/child's mouth, a visual and physical assessment of my infant(s) and a breastfeeding session. I understand that the advice, educational information and/or breastfeeding equipment supplied by the Lactation Consultant is to help my infant(s) and I.  

I understand that this may include referrals to other care providers as part of a holistic breastfeeding plan.

I understand a written/oral care plan will be given to address and assist in improving our breastfeeding situation and that both Myself and the Lactation Consultant have responsibilities in this plan.

I acknowledge that Heather Martin, IBCLC,RLC and Beyond the Breast Lactation Services are not certified or licensed by the State of Texas or the International Association of Aromatherapists.

I understand that the recommendations for Allopathic or Homeopathic remedies to include medications and essential oils are recommendations so only and further guidance should be gained from our Primary Care Providers.

I understand that much of the success of the Breastfeeding Care Plan is related to my ability to follow through and that I am responsible for informing Heather Martin, IBCLC, RLC of changes that I feel are necessary at the time of consultation or during the subsequent communications.

I understand that I will receive follow up contact to evaluate breastfeeding progress via email, text or phone calls or by Follow Up consultations if deemed appropriate.  

I understand that I may request a reassessment or Follow Up consultation if one is not suggested or scheduled at the close of my Initial Consultation.

I agree that Payment is Due at Time of Service.
I understand Cancellations with less than 24 hr notice will be assessed a Cancellation Fee.

I agree to be seen by Heather Martin, IBCLC,RLC (Beyond the Breast), give my consent and agree to the terms listed above by entering my name and consult date.