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Consent Form

Milkface Lactation Services Consent

I understand that during a consult for lactation support, an IBCLC from Milkface Lactation Services will examine me and my breasts both visually and manually, will examine me and my baby or babies both visually and manually (possibly 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 will provide Milkface Lactation Services with the names and contact information for other relevant healthcare providers for me and my baby, and Milkface Lactation Services may communicate with them. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for Milkface Lactation Services to send and receive texts and emails that may contain my Personal Health Information (PHI).

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 understand that if I include any third party on an email or text with Milkface Lactation Services, I am granting permission for Milkface Lactation Services to communicate my health information and that of my baby or babies with that third party. Milkface Lactation Services will not initiate inclusion of any third party on an email or text. I acknowledge that Milkface Lactation Services 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 understand that I am responsible for all charges associated with this visit. Milkface Lactation Services is providing care to me and to my baby or babies; together we are all the client of Milkface Lactation Services. Milkface Lactation Services may communicate with my insurance company in reference to the services provided to me and my baby or babies. Milkface Lactation Services 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 give permission to Milkface Lactation Services 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.

Thank you for trusting Milkface to help you with your breastfeeding relationship!

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