I give my consent for the lactation consultant to work with me and my baby during this consultation for my lactation problem/concern. This consent is for visits, phone conversations, and information sent by e-mail, fax or text, and includes appropriate follow-up contacts with health care providers as necessary and with myself or designated proxy. I understand that a lactation consultation may involve: touching my breasts, chest and/or nipples for the purposes of assessment; inserting gloved fingers into my baby's mouth to assess suck; observation of a breastfeeding, and suggestions to enhance latch or position; demonstration of the use of equipment or supplies that may be recommended, and demonstration of techniques designed to improve lactation. I understand that I am responsible for informing the lactation consultant of changes I feel are necessary in the care path at the time of the visit or during the course of follow-up communications. Phone / e-mail contact during the time following the lactation visit is crucial and considered an extension of the visit. Email may be sent to jennifer@labelledoula.com. I understand it is my responsibility to advise 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, referring physician, referring lay counselor, and/or our insurance company upon request. I understand the lactation consultant may contact my physician or my child’s physician if the lactation consultant feels it is necessary to consult with the physician. 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 will not 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 will receive an invoice to submit to my insurance company for consideration of reimbursement. 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, and the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that a student lactation consultant may be present to observe my consultation. I have received a copy of this provider’s Notice of Privacy Practices.