The Breastfeeding Doc Informed Consent for Lactation Consultation for Both Virtual and In-Person

    The Breastfeeding Doc Informed Consent for Lactation Consultation for Both Virtual and In-Person

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

    Dr Chinny is an International Board Certified Lactation Consultant (IBCLC); These consultations vary, but usually involves obtaining your presenting complaint, reviewing your health history, discussing your concerns, completing an assessment including visual inspection of your baby and your breasts where needed, evaluation of your baby’s mouth and suckling skills, answer your questions and develop a care plan with you.

    She will also provide you with information, handouts and resources based on your management plan.

    I authorize the IBCLC 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 purposes of assessment, make suggestions for techniques, equipment and supplies to improve breastfeeding.
    I grant permission to the IBCLC and The Breastfeeding Doc to release any information obtained in this consultation, whether of myself or my baby (ies) with my General Practitioner and health care providers, to further the knowledge of breastfeeding. I understand the IBCLC may contact my GP or my child’s GP when needed.
    I authorize the IBCLC and The Breastfeeding Doc to permit the presence of such observers, such as student IBCLCs, as they may deem fit to admit in addition to the IBCLCs while I am undergoing IBCLC consultation.
    In connection with the IBCLC services which I am receiving from my IBCLC, I consent that photographs may be taken of me or parts of my body, by my IBCLC or their approved photographer, for use or publication in medical records, medical research, medical journals, medical books, education and/or science; however, that it is specifically understood that in any such publication or use I shall not be identified by name. The aforementioned photographs may be modified or retouched in any way that my IBCLC, in said consultant's discretion, may consider desirable.
    I understand that our success with breastfeeding is important to my IBCLC, but we are responsible for our own progress on a weekly basis based on the recommendations and suggestions offered by my IBCLC. I agree to hold harmless and indemnify The Breastfeeding Doc and my IBCLC for any outcome my baby or I may experience.
    I acknowledge that my personal information will be held confidential by my IBCLC according to HIPPA guidelines. However, if I initiate or request electronic communications via text/email/messaging service, the platform I use may not be encrypted, secure and/or private, thus I grant my IBCLC permission to communicate with me by the method of my choice. If I decline to grant this permission, my IBCLC may only communicate with me by phone or mail.
    I agree that good communication is vital to our relationship and agree to bring any questions or concerns I may have about services, fees, billing, payment or scheduling, to my IBCLC’s attention.
    Name
    Name
    First
    Last