Release of liability and consent to treatment

A lactation consultation, whether in person or virtual, typically includes visual and physical assessment of the breastfeeding parent’s breasts, visual and physical assessment of the infant’s mouth and body, observation of the breastfeeding parent and infant nursing, analysis of the data relating to the breastfeeding situation, demonstration of techniques for improving breastfeeding, and sometimes the use of breastfeeding equipment. I give permission for Jessica Bliss, IBCLC, to do all of the above. 

I understand that all medical care is to be provided only by a physician(s). I give my permission for information about this and all additional consultations to be sent to my attending physician(s)/health care provider(s). 

I understand that the lactation consultant will make recommendations toward helping me reach my breastfeeding and lactation goals. I understand no outcome can be guaranteed. It is my responsibility to evaluate the effectiveness and sustainability of this care plan, and to contact my lactation consultant for advice, adjustments, and follow-up as necessary. 

I understand that my session includes one week of follow-up support with the lactation consultant. After that time, for additional questions or requests for additional lactation support, I will need to request a follow-up consultation. 

I understand that I have the right to refuse any or all specific techniques suggested, equipment to assist or remedy breastfeeding or lactation problems, and/or all recommended actions. 

I acknowledge that Jessica Bliss has provided their HIPAA policy. 

I understand that email and text are not inherently secure means of communication. If I choose to email or text Jessica with questions about lactation or breastfeeding, she will take all reasonable precautions to protect my privacy but cannot guarantee the security of those messages. 

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 acknowledge that Jessica Bliss is not responsible for any breech of confidentiality made by anyone I invite to be present during a visit, or anyone added by me as a third party to text or email. 

I give my permission for information from this consultation to be used to further the knowledge of breastfeeding and/or educational purposes. 

I understand that my identity and the identity of my chill(ben will be kept private. I understand that no specific names will be publicly used. 

I understand that this consultation is not being recorded, and that no pictures or videos will be taken or shared from this consultation without me providing prior written consent. 

I have read and reviewed Bright Star Lactation’s payment policies and acknowledge that I am responsible for all charges associated with this visit. 

I give my permission for information to be released to my insurance company to assist in the evaluation of a claim. 

I give my permission for Jessica Bliss to bill my insurance and collect payment if I have not paid cash at the time of service. 

I give Jessica Bliss permission to bill my credit card on file if I have chosen a self-pay option. I have been given the cash rates for consultations.