Consent Form

• I give my consent for the lactation consultant to work with me and my baby during this consultation for my breastfeeding problem/concern. This consent is for visits, phone conversations, and information sent by e-mail, or text, and includes appropriate follow-up contacts.

• 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 equipment or supplies and techniques.

• I understand it is my responsibility to call the lactation consultant with progress reports, questions or concerns.

• I give my consent for the lactation consultant to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers. I understand the lactation consultant may contact my GP or my child’s GP if the lactation consultant feels it is necessary.

• I give my consent for the lactation consultant to use clinical information obtained during our sessions for education of other health care providers and mothers about lactation. I won’t be identified in any way, but aspects of my situation may be described and discussed.

• I understand total payment is expected at the conclusion of the consultation.

• I understand that for this lactation consultation and all follow-up, the lactation consultant will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners, the Standards of Practice of the International Lactation Consultant Association.

 

Signed __________________________________ Date ______________

·         In accordance with GDPR 2018 you must be informed what Data will be requested from you, how that Data will be processed or shared and what your rights are in relation to that Data. I will only request information that I need in order to provide her services effectively and safely. I will retain your consultation Data for a period of 25 years as per Government requirements. Your information will not be used for marketing purposes. The Data held about you will include name, age, address, email, your child’s name and date of birth, medical history, consultation notes, and may include a baby’s weight chart, care plan and a report to your GP. Information may be shared with your health professionals (see above). You have the right to request access to your personal Data. You also have the right to correction of that Data and deletion (where appropriate). If you are not happy with how your Data is managed, you have a right to complain. I reserve the right to contact you in the future regarding other services.

 

Signed __________________________________ Date ________________