Lactation Services

Consent

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, fax 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 the use of equipment or supplies that may be recommended, and demonstration of techniques designed to improve breastfeeding.
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 / text contact during the time following the lactation visit is crucial and considered an extension of your visit. You will be given an email address to report progress or to communicate continued problems or concerns. 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 breastfeeding 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 identifed 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.

If client agrees with the above, please sign *

clear

Today's Date *

*

Single Baby

Twins

Triplets

Date/Time of Consult *

Mother's First Name *

Last Name *

Mother's Date of Birth *

Baby's Name *

Baby's Date of Birth *

Baby's Age Today *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Mother's OB/Midwife *

Hospital

Practice Fax#

Pediatrician *

Practice Fax#

Delivery Type *

Were you induced? *

Yes

No

Birth Weight *

Discharge Weight *

Gestational Age at Birth *

Describe as best you can what your biggest challenges/concerns are *

Mark all that apply *

Infant Health

Did baby have any of the following during or after birth? *

Does baby have any known health problems? *

#of Wet diapers in past 24 hours *

#Stool diapers in past 24 hours *

Stool Color? *

Have you needed to supplement? *

Have you pumped? *

Maternal History

Is this your first baby? *

Yes

No

Did you breastfeed your other babies?

If no, how many other children do you have

Check all of the following that apply to your medical history

Please list your current medications including vitamins and over the counter meds *

Labor and Delivery

	Induction	Pitocin	Antibiotics	Epidural	Spinal	Excessive bleeding
Did you have any of the following in labor	Induction	Pitocin	Antibiotics	Epidural	Spinal	Excessive bleeding

Breastfeeding History

Did you notice breast change first trimester? *

Yes, significant

Yes but minor

No, not at all

Have you been pumping? *

Is your milk in yet? *

When did you first nurse the baby? *

Did the baby need to be supplemented in the hospital *

Are you currently supplementing with formula?If so which type, how often and how much *

Nipple pain/cracks/blisters	Plugged ducts	Internal breast pain
Mastitis	Painful latch	Engorgement
Low milk supply	Pumping concerns	Frustration/Anxiety
None	Other Other

Breech presentation	Cord around neck
Meconium aspiration	Breathing difficulties
Low blood sugar	Jaundice
None	Other Other

Breast surgery	Preeclampsia	Thyroid condition
Gestational dibetes	Infertility/assisted conception	Polycystic ovary syndrome
Anxiety/Depression	Other Other

No	I'm not sure
Yes	Yes and I'm engorged
Yes, I have been nursing for awhile