Consent Form

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Consent Form

Please read the information below. By typing your name, you accept the terms listed.

Email *

Name *

Phone number *

Address

Who is your baby's Pediatrician *

Who is your OB or Midwife? *

How did you hear about GROW? *

Pediatrician

OB/Midwife

Friend

Social Media

Google

Pediatric Dentist/ENT

Other:

Baby's Name *

What is your baby's date of birth? *

YYYY

What was your baby's birth weight? *

Does your baby have any underlying health conditions? *

Are you experiencing any of the following? Check all that apply. *

Pain with latching

Nipple damage (Cracks, bleeding, bruising, blanching)

Low Milk Supply

Infant is struggling to gain weight without supplementation

Infant has squeaky breathing noises when feeding

I hear clicking when my baby is feeding at the breast or on a bottle

Colicky baby

My baby refuses a bottle

I've been told my baby has a tongue or a lip tie

My baby has had a tongue or lip tie release but we're still having feeding difficulties

Low milk output when pumping

I just want to make sure feeding is going well

Required

Do you have a history of any of the following? Select all that apply. *

PCOS

Insulin Resistance

Diabetes (Type 1, Type 2, or Gestational)

Thyroid disfunction

Breast augmentation

Auto-immune disease

Infertility

N/A

Required

What is your goal for the appointment? *

Thank you for scheduling a lactation consultation with GROW Lakeland, LLC! We look forward to partnering with you during your breastfeeding journey. As a client of GROW, your consult(s) will be conducted by an International Board Certified Lactation Consultant (IBCLC). Please provide your initials and signature to confirm your understanding and acceptance of the following statements.

I understand that my lactation consultation(s) might include any or all of the following: visual and physical assessment of my breasts, observation of my baby nursing, visual and physical inspection of my baby’s mouth, and demonstrations of breastfeeding technique and equipment.

I understand that for the lactation staff to properly address my questions and concerns, it will be necessary for me to share information about my baby’s breastfeeding history and feeding behaviors. I understand that information about other maternal or infant health conditions is important to divulge, as is information about my baby’s birth experience. I agree to provide this information to the best of my ability.

If either myself or my baby requires medical care, I give permission to GROW to share information with my other health care provider(s) about my lactation appointment(s) as it pertains to that care. I understand that recommendations given to me by a primary care physician supersede those given by the staff at GROW, though I am encouraged to discuss all of my options for care with that physician.

I understand that payment for the lactation consult is due at the time of service. Upon my request, I will receive from GROW a form that I can use to submit a claim to my health insurance company for payment reimbursement. I give permission for information to be given to my health insurance company to clarify any issues regarding this claim.

I understand that I have the option to decline any treatment or use of equipment that is recommended during the consultation(s).

Follow-up care may be necessary. I understand that it is my responsibility to contact the lactation consultant with questions and concerns as they arise. The lactation consultant and I will determine together if a follow-up consultation would be beneficial.

If a visual record is needed for my file, I give permission to have my baby and/or me photographed or videotaped during the consultation. I understand that the images will only be used to assist in creating an appropriate care plan and will be kept private, never to be used for marketing purposes or shared in a public manner unless my written consent to do so is given.

I give permission for details about my consultation to be shared with other lactation professionals whose input can be helpful in creating my care plan. I understand that identifying information will not be shared.

I would like to opt-in to receiving communication from my consultant via text message, which is not HIPAA compliant. I understand that I can revoke permission at any time by contacting my counselor.

Are you okay with student participation? GROW has an amazing and highly skilled intern who is tracking her hours to qualify for the IBLCE board exam. All student interactions will supervised by Stephanie -- the IBCLC and owner of GROW Lakeland to ensure that you're receiving the highest standard of care. *

Yes

Clients are sometimes asked if they are okay with having pictures or video taken during their appointment for social media and/or learning opportunities. You will always be asked prior to any recording or photographs being taken. Would you allow GROW Lakeland, LLC to use images or videos of you and your baby on their social media page? *

yes

Do you have insurance? If so, please tell me which insurance plan you have. Please also mention if you see the multiplan logo, or the letters "PPO" or "HMO" as this will help me to determine coverage quicker.

For example: You have a BCBS policy and see PPO at the bottom of the card.

I understand that there is a $20 no-show / cancellation fee for any appointment that is not cancelled with a 24 hour notice.

Please type your first and last name below to acknowledge and accept any applicable cancellation fees.

Name on credit card *

Credit card number *

Expiration Date *

CVV code *

zip code *

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