Consultation Consent Form

  • I am requesting a breastfeeding consultation with an International Board Certified Lactation Consultant for myself and my infant/s. The consultation will include, but not be limited to a visual examination and manual palpation of my breasts as well as an examination of my infant’s mouth, sucking patterns and observation of a breastfeeding session. While the advice given by my Lactation Consultant is effective in most instances, I understand that these recommendations may not completely remedy or prevent adverse symptoms. The success depends, in large part, on my follow through with the recommendations. I understand that my physician(s) are my primary health care providers for myself and my baby and that he/she is responsible for the overall care of us. I will receive written recommendations at the end of this visit and I agree to NVLC faxing or mailing a copy of these recommendations to my physician(s). I give permission for information to be released to my health insurance company in the evaluation of claims for reimbursement for this consultation.