Consent For Care for In-Person Lactation Visits

 

I understand that during a consult for lactation support, Milky Way Lactation IBCLC will examine me and my breasts 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 will provide Milky Way Lactation with the names and contact information for other relevant healthcare providers for me and my baby, and Milky Way Lactation 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 Milky Way Lactation to send and receive texts and emails that may contain my Personal Health Information (PHI). Because Milky Way Lactation will be coming to my home, I grant permission for Milky Way Lactation to give my address to Joshua Strayer, and I understand that Milky Way Lactation will use GPS to navigate to my home.

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