Consent For Care for In-Person Lactation Visits

I understand that during a consult for lactation support, Heather Cordova 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 Heather Cordova IBCLC with the names and contact information for other relevant healthcare providers for me and my baby, and Heather Cordova IBCLC 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 Heather Cordova IBCLC to send and receive texts and emails that may contain my Personal Health Information (PHI). Because Heather Cordova IBCLC will be coming to my home, I grant permission for Heather Cordova IBCLC to give my address to Paul Cordova (Spouse), and I understand that Heather Cordova will use GPS to navigate to my home.

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 Heather Cordova 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 Heather Cordova IBCLC I am granting permission for Heather Cordova IBCLC to communicate my health information and that of my baby or babies with that third party. Heather Cordova IBCLC will not initiate inclusion of any third party on an email or text. I acknowledge that Heather Cordova 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 Heather Cordova’s payment policies and understand that I am responsible for all charges associated with this visit. Heather Cordova IBCLC is providing care to me and to my baby or babies; together we are all the client of Heather Cordova IBCLC. Heather Cordova IBCLC may communicate with TLN in reference to the services provided to me and my baby or babies. Heather Cordova IBCLC may communicate with my bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information.

I give permission to Heather Cordova 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.

Love Lactation, LLC