Privacy Policy

The lactation consultant is an allied health care provider and responsible for evaluating and recommending a plan of care to resolve or improve breastfeeding issues. 

By reading and signing this consent form you authorize Leanne Rzepa RN BN IBCLC (Registered Nurse and Lactation Consultant) to do all of the following: 

A lactation consultation with Nourish may include: 

  •  Visual and physical assessment of the mother’s breasts

  •  Visual and physical assessment of the infant’s mouth

  •  Taking a weight on the infant before and after breastfeeding

  •  Observation of the mother and infant nursing 

  •  Analysis of the data relating to the breastfeeding situation 

  •  Demonstration of techniques for improving breastfeeding 

  • Sometimes the use of breastfeeding equipment 

 I understand that for this lactation consultation and all follow-up consultations, Leanne Rzepa RN BN IBCLC will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners, and the Standards of Practice of Registered Nurses and the International Lactation Consultant ________

 I understand that I am responsible for informing the lactation consultant of changes I feel are necessary to the plan of care at the time of the visit or during the course of follow-up communication. _________

 I understand that lactation consultation does not substitute for medical care, and that medical care can only be provided by a physician. Any advice given in the course of this consultation or through phone/text support after this consultation, cannot replace medical advice received from a primary care provider. I understand that it is my responsibility to discuss any change in my care plan with my primary care provider._________

 I authorize the lactation consultant to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers or insurance company upon request. _________

 I understand that follow-up visits are sometimes necessary and cost $100 per visit or $90 per visit if a breastfeeding support package is purchased._______

 I understand that I may need to acquire breastfeeding supplies, products or equipment as recommended in the patient’s plan of care. Only effective breastfeeding supplies, products, and equipment will be recommended. _________

 I understand I will be given an email address and phone number to call or text to report progress or to communicate continued problems or concerns._________

 I understand that electronic or cellular forms of communication may not be encrypted or secure and that the lactation consultant cannot guarantee privacy when using cellular communications.__________

 I understand that payment is due at the time of services rendered. _________

 An invoice will be provided at the time of consultation for you to submit to your insurance company for reimbursement._______

 

_______________________________________ Mother's Signature _______________________________________ Mother's Name 

 

Date _______________________________________ 

 

Lactation Consultant's Signature ________________________________

 

Lactation Consultant's Name ___________________________________