Lactation Consent to Treat

I, pursuant to my signature set forth below, give my consent for Fifty-Two B.E.A.M.S. to work with me and my baby during the duration of my consultation and services with Fifty-Two B.E.A.M.S., whether one or multiple sessions, for my breastfeeding problem/concern. This consent is for in-person visits as well as phone conversations.

  • I understand that a lactation consultation from the Company may involve:

    • Touching my breasts and/or nipples for the purposes of assessment

    • Inserting a gloved finger into my baby’s mouth to assess suck and/or check for potential oral aversions that may prohibit a good latch (tongue tie, lip tie, etc.)

    • Observation of a breastfeed, 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 phone consultation or in person follow-up visit is sometimes necessary. I understand that breastfeeding supplies and/or breast pumps may be recommended as effective management of specific situations.

  • I understand that I am responsible for informing the Lactation Consultant of changes that I feel are necessary for the plan of care at the time of the visit or during follow-up communications. I understand it is my responsibility to call the Lactation Consultant with questions or concerns.

  • I give my consent for the Lactation Consultant to use clinical information and any photographs obtained during our sessions for discussions with other health care providers and education of mothers about lactation. I won’t be identified in any way, but aspects of my situation may be described and discussed.

  • I understand that for this lactation consultation and all follow-ups, 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, and the Standards of Practice of the International Lactation Consultant Association.

  • I have received and have been given an opportunity to view and sign the HIPPA form provided by Fifty-Two B.E.A.M.S.