I am requesting a breastfeeding consultation for myself and my infant(s).

I give my consent for the lactation consultant to work with me and my baby during this consultation for my breastfeeding problem/concern.

This consent is for face-to-face visits and all follow-up contacts; it includes phone conversations, and information sent via the Internet, fax or regular mail.

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 of the use of equipment or supplies that may be recommended, and
-demonstration of techniques designed to improve breastfeeding.

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. I won't be identified in any way, but aspects of my situation might be described and discussed.

I understand that total payment is expected at the conclusion of the consultation.

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 Health Insurance Portability and Accountability Act of 1996 (HIPAA).