Consent for Lactation Assessment and Exam

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Must be completed prior to consult. To be completed by the breastfeeding or chestfeeding parent.

Email *

I consent to a consult for lactation support for myself and my child with Charlotte Lactation LLC/Cheryl Demers, IBCLC. I am the parent (or legally authorized representative). With express permission granted at the time of the visit, Charlotte Lactation/Cheryl Demers, IBCLC will examine me and my breasts both visually and manually (during in-person home visits), will examine my baby or babies both visually and manually including an oral exam with a gloved finger (during in-person home visits), will observe me and my baby while feeding (if applicable), will make clinical observations, will provide information on techniques and breastfeeding equipment, and will make recommendations towards helping me reach my breastfeeding goals. *

Yes

Text is not a secure form of communication. Charlotte Lactation does use encrypted email software. As with phone calls or in-person communication, there is always a chance that private information may be overheard or shared. I am aware of the risk associated with texting and will consider these risks prior to initiating messages. I am aware that in-person conversations are recommended. Because Cheryl Demers will be coming to my home (during in-person home visits), I understand that Cheryl Demers will use GPS to navigate to my home and may share her whereabouts with her partner. Cheryl Demers will text to confirm address and time of visit but will not convey additional protected health information. *

Yes

I will provide Cheryl Demers with the names and contact information for other relevant healthcare providers for me and my baby(ies), and Cheryl Demers may communicate with them. It is my responsibility to provide accurate information and to keep it updated. *

Yes

I understand that the information and advice shared during these sessions does not constitute medical advice. I understand that all medical care is to be provided by my/our healthcare provider. *

Yes

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 (see below) to Cheryl Demers 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 Cheryl Demers, I am granting permission for Cheryl Demers to communicate my health information and that of my baby or babies with that third party. Cheryl Demers will not initiate inclusion of any third party on an email or text. I acknowledge that Cheryl Demers 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. *

Yes

Name of Person(s) I wish to have present during consult.

Cheryl Demers is providing care to me and to my baby or babies; together we are all the client of Cheryl Demers. Cheryl Demers 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 understand payment is due to Charlotte Lactation at time of both virtual and in-person home consultations. Payment may be paid with cash, credit card, HSA or FSA cards. Charlotte Lactation uses Square to provide appointment reminders and take payment. *

Yes

For a telehealth/virtual consult: If we are unable to connect to the HIPAA compliant platform provided by Cheryl Demers, we may use a non-HIPAA compliant platform of my choice, as long as it is private.

Yes

Clear selection

I give permission to Cheryl Demers 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. *

Yes

I sometimes have interns shadow me for mentoring purposes. Please choose yes if you give consent for an intern to observe our sessions, no if you do not. If you choose yes, I will notify you if an intern will be joining. It's totally fine to choose no, I don't mind. *

Yes

I have viewed the Notice of Privacy Practices, available at https://charlottelactation.com/new-page-1. Initial here that you have read, understand and agree. *

Yes

I certify that the above information is accurate and correct. *

Yes

Client Name *

Baby Name(s) *

Send me a copy of my responses.

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