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Consent Form
Consultation
A lactation consultation normally includes visual and physical assessment of the baby’s mouth and the mother’s breasts, observation of the baby breastfeeding, analysis of the breastfeeding history, demonstration of techniques to improve breastfeeding and sometimes use of equipment.
I give permission for Lactation Consultant Mo Brownlee of Nurture Breastfeeding to carry out the above.
I understand that I have the right to decline any or all suggested techniques, equipment or actions.
I understand that all medical care is to be provided by our doctor and health care professionals. I give permission for information to be shared with them if required. I understand that Mo Brownlee is required to share information with relevant professionals if she has cause for concern about client or baby welfare.
Record keeping
I understand that a record will be completed during the consultation which will contain personal and medical information and that this record will be securely held by Nurture Breastfeeding in accordance with the NHS Code of Practice (Scotland) 2012. I give permission for this and understand that I can ask for access to the record at any time.
I give consent for a record of my contact details to be securely maintained in accordance with General Data Protection Regulations (May 2018). I understand this information is for the use of Nurture Breastfeeding only and will never be disclosed to or shared with a third party.
Payment
I agree to reimburse Mo Brownlee IBCLC, as per stated terms and conditions, on receipt of an invoice. I acknowledge that cancellation with less than 24hr notice may incur a fee.
