I understand that during a consult for lactation support, a Lactation Consultant for Virtual Breastfeeding Inc. will examine me and my breasts visually, will examine me and my baby or babies visually, will observe me and my baby while feeding, will make clinical observations, will provide information on techniques and breastfeeding equipment, and will make recommendations towards helping me reach my breastfeeding goals. I understand no outcome can be guaranteed.
I will provide the lactation provider with the names and contact information for other relevant healthcare providers for me and my baby, and the Lactation consultant may communicate with them. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for Virtual Breastfeeding Inc. to send and receive texts and emails that may contain my Personal Health Information (PHI). I understand that it is my choice to have someone else present during the visit, and that anyone who sits in on the visit will have access to my healthcare information and my confidentiality may not be guaranteed. I have provided written notice to Virtual Breastfeeding Inc. of any person(s) I wish to have present during the visit. I understand that if I include any third party on an email or text with Virtual Breastfeeding Inc., I am granting permission for Virtual Breastfeeding Inc. to communicate my health information and that of my baby or babies with that third party. Virtual Breastfeeding Inc. will not initiate inclusion of any third party on an email or text. I acknowledge that Virtual Breastfeeding Inc. is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party to text or email.
I have read and reviewed Virtual Breastfeeding Inc.’s payment policies and understand that I am responsible for all charges associated with this visit. Virtual Breastfeeding Inc. is providing care to me and to my baby or babies; together we are all the client of Virtual Breastfeeding Inc.. Virtual Breastfeeding Inc. may communicate with my insurance company in reference to the services provided to me and my baby or babies. Virtual Breastfeeding Inc. may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information.
I give permission to Virtual Breastfeeding Inc. to photograph or record video of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my baby’s healthcare team.

Consent for Care for Telelactation

I understand that during a virtual consult for lactation support, Virtual Breast feeding lactation consultant may examine me and my breasts visually, may examine me and my baby or
babies visually, may observe me and my baby while feeding, may make clinical
observations, may provide information on techniques and breastfeeding, pumping, and
feeding equipment, and will make recommendations towards helping me reach my goals.
The Lactation Consultant will guide me in positioning my camera to be able to see me
and my baby, and will direct me in assessments of my breasts and/or my baby in the
furtherance of my care.
I understand no outcome can be guaranteed. I acknowledge that there may be some
limitations with virtual care.
I will provide Virtual Breastfeeding ; with the names and contact information for
other relevant healthcare providers for me and my baby, and Virtual Breastfeeding ;
may communicate with them. It is my responsibility to provide accurate information and to
keep it updated.
I understand that it is my choice to have someone else present during the visit, and that
anyone who sits in on the visit will have access to my healthcare information and my
confidentiality may not be guaranteed. I have provided written notice toVirtual Breastfeeding; of any person(s) I wish to have present during the visit. I understand that if I
include any third party on an email or text with Virtual Breastfeeding, I am granting
permission for Virtual Breastfeeding; to communicate my health information and
that of my baby or babies with that third party. Virtual Breastfeeding; will not initiate
inclusion of any third party on an email or text. I acknowledge that Virtual Breastfeeding; is not responsible for any breach of confidentiality made by any person present I
invite to be present during a visit, or added by me as a third party to text or email.
I have read and reviewed Virtual Breast feeding’s payment policies and understand
that I am responsible for all charges associated with this visit. Virtual Breastfeeding;
is providing care to me and to my baby or babies; together we are all the client of Virtual Breastfeeding; may communicate with my insurance
company in reference to the services provided to me and my baby or babies.Virtual Breastfeeding; may communicate with my credit card company or bank for any payment
related matters. It is my responsibility to provide accurate and current payment and
insurance information.
I give permission to Virtual Breastfeeding; to photograph or record video of me
and/or my baby in furtherance of my care. These photos will not be published without my
express consent, but they may be shared with my or my baby’s healthcare team.
If you are unable to access secure video:

In order to provide care to you I am using a HIPAA compliant
service; to provide video care for you and your baby.

Web-based EHR platforms
Use this script with any EHR platform that uses a web-based login for secure messaging.
If you would like to use secure messaging to communicate with me, you can log into your chart on Charm at any time. By using secure messaging, I can ensure HIPAA security, and our communication will be stored in your chart.
You are not obligated to use secure texting, I’m just required to offer it. If you opt out of secure texting and send me a regular text or email, I’ll respond. My emails are stored on a secure server and encrypted.