Lactation Consultation Consent
By reading and signing this Consent Form, you give the following consent, and agree to the terms in this document.
I consent for Mayvina Wee, a certified breastfeeding specialist (CBS), to work with my baby and I during this consultation for my breastfeeding problem/concern. This consent covers all forms of consultation, including but not limited to in-person visits, video-call, phone calls, and messaging consultations. At times, information may be sent by email or over WhatsApp.
1. I understand that an in-person lactation consultation home visit may involve:
o Visual and physical assessment of the your breasts which may involve touching of breasts and/or nipples.
o Visual and physical assessment of the infant’s mouth.
o Observation of a breastfeed, and suggestions to enhance latch or position.
o Analysis of the data relating to the breastfeeding situation.
o Demonstrating the use of breastfeeding-related equipment, supplies. Subsequently, techniques may be recommended.
o Mirroring techniques taught during the session to ensure understanding and capability in the techniques.
2. I understand a partial or follow-up consultation is sometimes necessary.
3. I understand that I am responsible for informing the CBS of changes I feel are necessary for the care path at the time of the consultation or during the course of follow-up communications. Email/phone contact during the two weeks following the consultation is crucial and considered an extension of this visit.
4. I understand it is my responsibility to call the CBS with progress reports, questions, or concerns.
5. I understand any recommendations different from my physician’s (i.e. OBGYN, General Practitioner, medical doctor, etc.) recommendations should be discussed with the physician. Health care issues of a medical nature MUST be discussed with a physician.
6. I give my consent to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers, in cases when necessary. I understand that my or my child's health care provider may be contacted when necessary.
7. I give my consent for the CBS to use clinical information and any photographs (strictly only if mother consent for photographs to be taken. No photographs will be taken with the CBS’s phone.) obtained during our consultations conferring with the education of mothers about lactation for professional training and studying purposes. I won’t be identified in any way, but aspects of my situation may be described and discussed. Boundaries and privacy will be fully respected and honoured.
8. I understand that for this lactation consultation and all follow-ups, the CBS will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners, the Standards of Practice of the International Lactation Consultant Association.
9. Payments:
Single consultation: $50 pre-payment is required to secure the slot.
4th Trimester Support: $100 pre-payment is required to secure the slots. You may prebook both slots.
Payment must be made within 24 hours of appointment confirmation. I understand total payment is expected at the conclusion of the consultation.
10. Rescheduling for in-person home visits
Notify any changes in schedule at least 2 hours before the appointment.
o Please call or WhatsApp 8705 6039.
o Transport fee of $10-$20 will be charged if notice is given less than 2 hours before the appointment.
11. Cancellation for in-person home visits
Notify on your wish to cancel at least 2 hours before the appointment.
o Please call or WhatsApp 8705 6039.
o Pre-payment will be forfeited if cancellation notice is given less than 2 hours before the scheduled time.
12. Extended consultation (above 2 hours) will be charged at SGD 20 per every 10 minutes, subjected to availability. Payment must made after the consultation.
Last updated on 12 November 2024. Manna Milk reserves the right to update this consent form without any prior notice.