Consent for Care for In Person Visits and Privacy Policy.

Britt Pegan, IBCLC is providing care to me and to my baby or babies; together we are all the client of Milkface Lactation Services.

I understand that during a consult for lactation support, Britt will examine me and my breasts/chest both visually and manually, will examine me and my baby or babies both visually and manually (including an oral exam with a gloved finger), 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 give my consent to undergo such examination and assessment and know that I can withdraw my consent at any time and that I am free to bring an additional person to any session to act as my advocate.

This will be discussed with you further, prior to your examination and Britt will discuss any questions you may have regarding the exam.

Britt will protect my personal information using secure accounts that comply with all applicable privacy laws. Britt will provide me with policies and procedures related to the protection of personal information upon receipt of a written request.

I will provide Britt with the names and contact information for other relevant healthcare providers for me and my baby, and I authorize Britt to share my information as deemed necessary. I also understand that my personal and medical information is confidential and will only be disclosed to third parties (including medical doctor and healthcare providers) with my permission. 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 to Britt 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 Britt, I am granting permission for Britt to communicate my health information and that of my baby or babies with that third party. Britt will not initiate inclusion of any third party on an email or text. I acknowledge that Britt 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 Britt’s payment policies and understand that I am responsible for all charges associated with this visit. Britt may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment information.

Britt provides a secure messaging portal through Practice Better. I understand that I am not obligated to use secure messaging, and if I opt out of secure messaging by initiating communication by text or email Britt will respond. I understand that email and text are not secure means of communication, and give my permission for Britt to send and receive texts and emails that may contain my Personal Health Information (PHI) if initiated by me.

I give permission to Britt to photograph or record video and/or audio 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. I understand that Britt uses a PIPEDA compliant AI tool called Heidi to help create a record of our session today. Using this tool lets Britt give her full attention to me and my baby. I understand that my data and personal information is kept confidential and secure inside my account and will not be shared with any unauthorized person. I understand that the AI tool does not maintain a permanent record of any information regarding me, my baby or any care received.

Consent for Care for Telelactation

Despite efforts to ensure high encryption and secure technology, there is always a risk that the transmission could be breached and accessed by an unauthorized person. However, all services are provided using a secure platform compliant with all applicable privacy laws.

As Telelactation services are provided remotely, there is also a very mild risk of personal safety only in that there is no service provider directly with you to assist if you need. However, this would be no riskier than being at home alone. If you have significant mobility issues and/or do not feel safe being alone for care, we recommend you have someone present with you during your treatment.

Further, with an inability to perform hands-on examination, assessment via Telelactation may not be the most suitable treatment option. For this reason, in many circumstances and when available, similar in-person care would be preferable.

I understand that during a virtual consult for lactation support, Britt Pegan, IBCLC 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. I understand no outcome can be guaranteed. Britt 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 give my consent to undergo such examination and assessment and know that I can withdraw my consent at any time and that I am free to bring an additional person to any treatment sessions to act as my advocate.

This will be discussed with you further, prior to your examination and Britt will discuss any questions you may have regarding the exam.

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 Britt 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 <Britt, I am granting permission for <Britt to communicate my health information and that of my baby or babies with that third party. Britt will not initiate inclusion of any third party on an email or text. I acknowledge that Britt 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 Britt’s payment policies and understand that I am responsible for all charges associated with this visit. Britt is providing care to me and to my baby or babies; together we are all the client of Milkface Lactation Services. Britt may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment information.

Consent for Care for In Person Visits and Privacy Policy.

Consent for Care for Telelactation

Ottawa’s breastfeeding experts. ♡