Consent for Lactation Care Services
Little Hearts Lactation
Consent for Lactation Care Services
I, ______________________, hereby consent to receive lactation consulting and support services from Little Hearts Lactation, provided by Megan Jones, a Certified Lactation Counselor (CLC). I understand that these services may include, but are not limited to, breastfeeding education, latch and positioning assistance, milk supply guidance, and addressing breastfeeding challenges.
Purpose of Services
I acknowledge that the purpose of these services is to support my breastfeeding goals and promote the health and well-being of myself and my baby. I understand that lactation consulting is not a substitute for medical advice, diagnosis, or treatment from a licensed healthcare provider.
Scope of Services
I understand that the lactation consultant will:
Assess my breastfeeding situation through observation, discussion, and/or physical assessment (e.g., latch evaluation).
Provide education, recommendations, and a care plan tailored to my needs.
Offer follow-up support as agreed upon.
I consent to the lactation consultant performing hands-on assistance (e.g., adjusting latch or positioning) if necessary, and I will inform the consultant immediately if I am uncomfortable with any aspect of the care.
Risks and Benefits
I understand that while lactation support is intended to improve my breastfeeding experience, results cannot be guaranteed. Potential benefits include improved breastfeeding success, comfort, and confidence. Possible risks may include temporary discomfort during adjustments or emotional frustration if challenges persist. I have been given the opportunity to ask questions about the services and have them answered to my satisfaction.
Privacy and Confidentiality
I acknowledge that Little Hearts Lactation will maintain the confidentiality of my personal and health information in accordance with applicable privacy laws (e.g., HIPAA, if applicable). My information will not be shared without my written consent, except as required by law.
Photographs/Video (Optional)
I [ ] consent / [ ] do not consent to photographs or videos being taken during my session for educational or documentation purposes. If consented, these will be kept confidential and used only with my explicit permission.
Payment and Cancellation
I agree to pay the fees outlined by Little Hearts Lactation for services rendered. I understand the cancellations within 24 hours of the appointment may incur a fee of $50.00.
Voluntary Participation
I understand that my participation in these services is voluntary, and I may discontinue care at any time. I also understand that the lactation consultant may refer me to a physician or other healthcare provider if concerns beyond the scope of lactation support arise.
Signature
By signing below, I confirm that I have read and understood this consent form, and I agree to the terms outlined above.
Client Name (Print): _______________________________
Signature: _______________________________
Date: _______________________________
Lactation Consultant Name (Print): Megan Jones
Signature: _______________________________
Date: _______________________________