I give my consent for an MC Lactation Specialist to work with me and my baby for my specified breastfeeding challenge/concern. 

I understand that a visit with an MC Lactation Specialist may involve: viewing and touching of my breasts and/or nipples for the purpose of assessment and inspection, observation of my latch techniques and will offer advice and suggestions to correct/enhance the latch and/or positioning of my baby.

I understand that the MC Lactation Specialist may insert a clean, gloved finger into my baby’s mouth to check for normal suckling strength and/or abnormalities. 

I understand that the MC Lactation Specialist may also observe my baby’s diaper changes and view any diaper and feeding logs I have.

I understand that my visit may include the inspection of equipment such as my breast pump, pump accessories and or supplies and she may recommend other equipment or supplies to assist with my breastfeeding.

I understand that an MC Lactation Specialist will not perform any medical procedures, she will not provide a medical diagnosis, and she will not go against any recommendations my healthcare provider (including my baby's Pediatrician and my own medical doctor) has made. 

I understand that an MC Lactation Specialist is trained to identify areas that can potentially create challenges with breastfeeding, my milk production, and my baby's growth and development and shares this information with me so that I can connect with the appropriate healthcare provider if the issues she has identified require a medical professional's evaluation.

I understand that an MC Lactation Specialist will assist me by creating a detailed list of questions and concerns I should present to my provider or my baby's Pediatrician for further clarification. 

I understand that an MC Lactation Specialist will not offer “medical treatments” by prescribing or recommending medications (prescription or over-the-counter) but she can provide evidence-based information on various treatments, including medications if necessary, so that I can discuss treatment options with my provider or Pediatrician.

I understand and agree to inform my healthcare provider and/or Pediatrician about any supplements (galactagogues) that are commonly used to “increase” or “boost” breastmilk production BEFORE I use them.

I understand that I am responsible for informing the MC Lactation Specialist of changes I feel are necessary for her to know while she is assisting me with Lactation Services and during follow-up services.

I give my consent for the MC Lactation Specialist to release any information she has collected during our visit about myself or my baby to our healthcare provider, pediatrician, referring providers, and/or other Lactation Specialists should it be deemed necessary.

I understand that for this lactation visit and any follow-ups I may have, the MC Lactation Specialist will protect the privacy of my personal health information as required by law and the Health Insurance Portability and Accountability Act (HIPPA).