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Consent Form


•      I give my consent for the Breastfeeding Counselor to work with me and my baby for my breastfeeding issue/concern. This consent is for in-person visits, as well as virtual sessions.

 

•      I understand that a counseling session may involve:

  • Touching my breasts and/or nipples for the purposes of assessment using gloved fingers

  • Taking measurements of nipples to ensure correct size for pumping using a ruler or sizing chart

  • Inserting gloved fingers into my baby’s mouth to assess suck or adjust lip position during a breastfeeding session

  • Observation of a breastfeed, and suggestions to enhance latch or position

  • Demonstration and use of equipment or supplies that may be recommended

  • Demonstration of techniques designed to improve breastfeeding


 •  I understand that breastfeeding supplies and/or breast pumps, bottle feeding or formula supplementation may be recommended as effective management of specific situations.


 •  I give my consent for the counselor to use information obtained during our sessions for conferring with my health care provider when necessary.


 •  I understand that for this counseling session and all follow-ups, the breastfeeding counselor will respect the privacy of my personal health information.

•  I understand that a follow up visit may be recommended.


• I understand that Quick Lactation Support does not prescribe medications.


 •  I understand that Quick Lactation Support does not give refunds for services rendered.

Date
Month
Day
Year
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Mother and Baby Information (page 1 of 2)

Date
Month
Day
Year
Have you seen anyone else for this issue?
Yes
No
Did your breast change during pregnancy?
Yes
No
Did you breastfeed your other children?
Yes
No
Did you breastfeed as long as you wanted?
Yes
No

Medical History (check all that apply):

Allergies:
Yes
No
Alcohol Use:
Never
Occasionally (1-2 / week)
Daily
Have you ever smoked cigarettes?
Yes
No

Check all that apply to this pregnancy / birth:

Mother and Baby Information (page 2 of 2)

Infant History

Birthday or due date
Month
Day
Year

Do any of the following apply to your baby?

Breastfeeding experience in the hospital (check all that apply)

Do you think you received enough help during your stay?
Yes
No

Feeding in the last 24 Hours

Latching?
Yes
No
Sometimes
Takes both breasts at feedings?
Yes
No
Using a pacifier?
Yes
No
Do you have a breast pump?
Yes
No
Using the breast pump?
Yes
No
Giving bottles of breastmilk?
Yes
No
Giving bottles of formula?
Yes
No

Pain

Any pain with breastfeeding?
Yes
No
Any pain with pumping?
Yes
No
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