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Taylor-Made Lactation Consent For Care

Consent For Care for In-Person Lactation Visits

I understand that during a consult for lactation support, Taylor Aguirre IBCLC will examine me and my breasts both visually and manually, will examine me and my baby or babies both visually and manually (including an oral exam with a gloved finger), will observe me and my baby while feeding, will make clinical observations, will provide information on techniques and breastfeeding equipment, and will make recommendations towards helping me reach my breastfeeding goals. I understand no outcome can be guaranteed.

I will provide Taylor Aguirre IBCLC with the names and contact information for other relevant healthcare providers for me and my baby, and Taylor Aguirre may communicate with them. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for Taylor Aguirre IBCLC to send and receive texts and emails that may contain my Personal Health Information (PHI).

I understand that it is my choice to have someone else present during the visit, and that anyone who sits in on the visit will have access to my healthcare information and my confidentiality may not be guaranteed. I have provided written notice to Taylor Aguirre IBCLC of any person(s) I wish to have present during the visit. I understand that if I include any third party on an email or text with Taylor Aguirre IBCLC, I am granting permission for Taylor Aguirre IBCLC to communicate my health information and that of my baby or babies with that third party. Taylor Aguirre IBCLC will not initiate inclusion of any third party on an email or text. I acknowledge that Taylor Aguirre IBCLC is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party to text or email.

I have read and reviewed Taylor Aguirre IBCLC’s payment policies and understand that I am responsible for all charges associated with this visit. Taylor Aguirre IBCLC is providing care to me and to my baby or babies; together we are all the client of Taylor Aguirre IBCLC. Taylor Aguirre IBCLC may communicate with my insurance company in reference to the services provided to me and my baby or babies. Taylor Aguirre IBCLC may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information.

I give permission to Taylor Aguirre IBCLC to photograph or record video of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my baby’s healthcare team.

________________________________________________ Date __________________

By using this product, you attest that you have purchased a license for this product and are agreeing to the Usage Terms, Conditions, and Copyright found in the product documentation.

© 2022 Taylor-Made Lactation IBCLC Inc All Rights Reserved.

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