Registration and Consent

Mother's First Name *

Mother's Last Name *

Mother's Date of Birth * +

Street Address *

City *

State *

Zip Code *

Phone Number *

Cell Number *

Email Address *

Mother's Physician *

Mother's Occupation *

Father's First Name *

Father's Last Name *

Father's Date of Birth * +

Is Father's address the same *

Father's Occupation *

Infant's First Name *

Infant's Last Name *

Infant's Date of Birth * +

Infant's Physician *

Has baby seen the doctor yet? *

If so, when and what was the baby's weight? *

Infant's Place of Birth *

If Other, please specify here: *

Infant's Birth Weight? *

Infant's weight when you left the hospital: *

Who referred you? *

Consent and Agreement: Read and initial each section

I understand that Angela Hartfelder, International Board Certified Lactation Consultant, will be evaluating and recommending a plan of care to help me reach my breastfeeding goals. This evaluation will include obtaining a pertinent medical and personal history of myself, my infant, and the infant's father; and physical anatomy assessment of myself and my infant, observation of a feeding, and recommendations to help me achieve my breastfeeding goals. *

I understand that although it is the responsibility of the Lactation Consultant to make recommendations to help me reach my breastfeeding goals, I am responsible for implementing the recommendations. I am also responsible for notifying the Lactation Consultant if I feel I can not or will not implement the recommendations, so that changes can be made to better accommodate the needs of myself and my baby. *

I understand that I may need additional visits beyond the initial consultation. It is my responsibility to contact the Lactation Consultant to schedule follow-up visits for continuing evaluation, or evaluation of a new or different problem. *

I understand that I am responsible for calling the Lactation Consultant to report my progress at implementing the recommendations, as well as any further questions or concerns. Breastfeeding issues may take days or weeks to resolve, and may require implementing different or additional recommendations than those recommended during the initial consultation. *

I understand that it is my responsibility to contact my physician and/or my infant's physician regarding any medical health care issues to discuss any recommendations or changes from that physician's recommendations. *

I understand that in order to facilitate communication between members of the health care team of both myself and my infant, I authorize the Lactation Consultant to release any information obtained regarding myself and/or my infant to other members of our health care team and to contact them as needed. This may include, but is not limited to, my physician; my infant's physician; members of either physician's staff, including on-call providers; the hospital or facility at which my infant was born or transferred; and other health care professionals and/or therapists involved in the care of myself and/or my infant. *

I understand that I must pay, at the time of service, the stipulated fee for service to Angela Hartfelder, IBCLC. I understand that this fee is non-refundable, and is not conditional on the outcome of the consultation or follow-up visit(s). I further understand that if I cancel an appointment with less than 24 hours notice, or do not keep the appointment, I am responsible for a cancelation/no show fee of 50% of the visit fee, and it is immediately due and payable to Angela Hartfelder, IBCLC, and I authorize this fee to be charged immediately to the credit card information provided to reserve my consultation time. *

I understand that the Lactation consultant does not accept any insurance assignment or reimbursement. If I choose to seek reimbursement from my insurance company for my consultation or follow-up, it is my responsibility to complete the appropriate forms and conditions required by my insurance company. I understand that the Lactation Consultant is not a plan provider for any insurance plan, and for this reason reimbursement by my insurance company is not guaranteed. *

I understand that information and/or photographs from my consultation and/or follow-up may be used for professional development in the field of lactation, such as education, research, or professional collaboration. If used, this information will not include any personally identifiable information. *

I have been provided a copy of the Lactation Consultant's HIPPA Privacy Practices in electronic and/or written form. *

I understand that by affixing my name to this page,and my initials to the consent and agreement subsections, and submitting this form, that I am electronically signing this document and agree to be bound by the items therein. *