I give my consent for the lactation counselor to work with me and my baby during this consultation for my breastfeeding problem/concern.  This consent is for in-person visits, as well as phone conversations, and any information sent/communicated by e-mail, mobile phone, fax, SMS text messages, and/or private social media.  I understand that electronic/cellular forms of communication may not be encrypted/secure.I understand that a lactation consultation may involve:

  • Touching my breasts and/or nipples for the purposes of assessment;
  • Inserting gloved fingers into my baby’s mouth to assess suck;
  • Observation of a breastfeed, and suggestions to enhance latch or position;
  • Demonstration of the use of equipment or supplies that may be recommended, and o demonstration of techniques designed to improve breastfeeding.

I understand that I am responsible for informing the lactation counselor of changes I feel are necessary in the care path at the time of the visit or during the course of follow-up communications.  Contact during the time following the lactation visit is crucial and considered an extension of your visit.  I will be given a phone number to call to report progress or to communicate continued problems or concerns.  I understand it is my responsibility to call the lactation counselor with progress reports, questions or concerns.  I give my consent for the lactation counselor to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers, referring physician, and/or our insurance company upon request.  I understand total payment is expected before consultation.  I also understand that The Village Maternity Services does not give refunds for services rendered.  I understand that for this lactation consultation and all follow-ups, the lactation counselor will protect the privacy of my personal health information as required by the Health Insurance Portability and Accountability Act of 1996 (HIPPA).  I have received a copy of this provider’s Notice of Privacy Practices.