Consent Agreement

Introduction

Thank you for coming for a consultation. Before we proceed, I will need your consent to properly evaluate your presenting complaint and offer management.

About the Consultation

Dr Chinny is an International Board Certified Lactation Consultant (IBCLC). These consultations vary but usually involve:

• • Obtaining your presenting complaint

• • Reviewing your health history

• • Discussing your concerns

• • Completing an assessment, which may include:
    
    • • Visual inspection of your baby and your breasts where needed
    
    
    • • Evaluation of your baby’s mouth and suckling skills

• • Answering your questions

• • Developing a care plan with you

You will also be provided with information, handouts, and resources based on your management plan.

Consent for Consultation Activities

I authorize the lactation consultant to:

• • Hold my baby

• • Evaluate my baby’s suckling motions by touching the baby’s mouth

• • Observe us feeding and/or pumping

• • View and touch my breasts and/or nipples for assessment purposes

• • Make suggestions for techniques, equipment, and supplies to improve breastfeeding

Responsibility and Communication

• • I understand that it is my responsibility to follow the plan provided by the lactation consultant and to prepare progress reports, questions, or concerns for the follow-up session.

• • I agree that good communication is vital to our relationship and agree to bring any questions or concerns I may have.

Information Sharing

• • I grant permission to the lactation consultant to release any information obtained in this consultation, whether about myself or my baby(ies), with my General Practitioner and health care providers to further the knowledge of breastfeeding.

• • I understand that the lactation consultant may contact my GP or my child’s GP if necessary.

Educational Use of Information

• • I give my consent for the lactation consultant to use clinical information obtained during our session for the education of other health care providers and mothers about lactation.

• • I understand that I will not be identified in any way, but aspects of my situation may be described and discussed.

Photograph Consent

• • In connection with the lactation services I am receiving, I consent to photographs being taken of parts of the body related to the consultation, such as my baby’s tongue, latching position, nipple, etc., by my lactation consultant for complete assessment and educational purposes.

• • It is understood that in any such publication or use, I shall not be identified by name.

Acknowledgment of Responsibility and Indemnity

• • I understand that our success with breastfeeding is important to my lactation consultant, but I am responsible for our own progress on a weekly basis based on the recommendations and suggestions offered.

• • I agree to hold harmless and indemnify The Breastfeeding Doc for any outcome my baby or I may experience.

Confidentiality and Electronic Communications

• • I acknowledge that my personal information will be held confidential by my lactation consultant according to HIPAA guidelines.

• • However, if I initiate or request electronic communications via text, email, or messaging services, I understand that the platform I use may not be encrypted, secure, and/or private.

• • I grant my lactation consultant permission to communicate with me by the method of my choice.

Closing Statement

Please read through the above consent form carefully. By proceeding with the consultation, you are giving your consent to the terms outlined above.