• I give my consent for the Lactation Specialist 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.
• 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 breastfeeding, and suggestions to enhance latch or position.
• Demonstration and use of equipment or supplies that may be recommended.
• Demonstration of techniques designed to improve breastfeeding.
• I understand a partial or follow-up visit is sometimes necessary. I understand that breastfeeding supplies and/or breast pumps may be recommended for the effective management of specific situations.
• It is a private pay & needs to be paid upfront. We don’t deal with Insurance companies. If cancellation is not done in 24hrs $75.00 is charged.
• I understand that I am responsible for informing the Lactation Specialist of changes I feel are necessary in the care path at the time of the visit or during follow-up communications. I understand it is my responsibility to call the Lactation Specialist with progress reports, questions, or concerns.
• I give my consent for the Lactation Specialist to use clinical information and any photographs obtained during our sessions for conferring with other healthcare providers and educating mothers about lactation. I won’t be identified in any way, but aspects of my situation may be described and discussed.
• I understand that the Mothers Milk Matter financial policy I signed also applies to Lactation services. I also understand that Mothers Milk Matter does not give refunds for services rendered.
• I understand that for this lactation consultation and all follow-ups, the Lactation Specialist will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners, and the Standards of Practice of the International Lactation Consultant Association.

HIPPA regulations updated information needs to be sent via Mothers Milk Matters email to providers.