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1 Contact and general information 2 Lactation Intake Form 3 Breastfeeding Parent Health History 4 Baby’s Health History 5 Consent to Treat

CONSENT TO TREAT

Please read and check each box before signing

I understand that breastfeeding counseling by Andrea Lorenzo, may include a visual and manual assessment of the breastfeeding parent’s breasts, baby’s suck, observation of mother and baby breastfeeding, analysis of information relating to the breastfeeding situation, demonstration of techniques for improving breastfeeding, use of breastfeeding equipment, and recommendation of a treatment plan to resolve breastfeeding issues, which may be adjusted during the course of treatment.

I hereby give consent for treatment according to the scope of practice. I understand that I am responsible for informing Andrea of any relevant information or changes that affect my breastfeeding situation.

I understand that it is my responsibility to contact Andrea with progress reports, questions and concerns.

I understand that the results are not guaranteed. I do not expect Andrea to be able to treat all complications effectively and understand that she will be able to explain all treatments and recommendations as well as the desired effect of said treatment.

I understand that in some instances it will be necessary to refer me to other care providers.
With this knowledge, I voluntarily consent to working with Andrea. I intend this consent form to cover the entire course of treatment. I understand that I am free to withdraw my consent at any time.

Consent to share information about your case for other purposes

Please initial next to each line where the proposed documenting or sharing of your information is acceptable to you. You can choose not to give permission for any of the additional use of your health information. You can revoke the permissions at any time. You must notify Andrea Lorenzo in writing to revoke permissions. Please note that the consent to sharing of information to healthcare providers is necessary in order to provide care. The permissions below are in addition to the required permissions.

Andrea Lorenzo may share information about my case with other lactation consultants/counselors in order to gather information to better treat my case. This includes, but is not limited to: verbal communication, email communication and social media.

Andrea Lorenzo may share information about my case with other lactation consultants/counselors in order to help educate or provide potentially valuable information that may help treat others. This includes, but is is not limited to: verbal communication, email communication or social media.

Andrea Lorenzo may communicate about my case with the following individuals. (Examples may include a spouse, parent, sibling or friend).

Andrea Lorenzo may communicate about my case with the following individuals. (Examples may include a spouse, parent, sibling or friend).

Consent to photograph

Andrea Lorenzo may take pictures or videos in order to document or treat my case. Any photo or video taken for this purpose may be shared with your or your baby’s health care providers. You will always be asked for permission before any photo or video is taken.

Andrea Lorenzo may take my picture or my baby’s picture or videos in order to document my condition for the purposes of educating others. You will not be identified in this picture. You will always be asked for permission before any photo is taken.

My signature below acknowledges that I have read and understand the information contained in this document. I have been given a chance to ask questions and they have been answered to my satisfaction. I give Andrea Lorenzo permission to share my personal information and information about my case with my healthcare providers, my child’s healthcare providers.