Consent Form
This form takes about 5 minutes to complete. Please make sure to complete all required fields.
Client Preferred Name
Client Full Name
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First Name
Last Name
Client Birth Date
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Day
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Month
Year
Date
Age
Occupation
Address
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Street Address
Street Address Line 2
Town
County
Post Code
Contact Number
Format: 00000 000000.
E-mail
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How did you find out about my services?
Partner's Name
First Name
Last Name
Baby's Information
Baby's Full Name
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First Name
Last Name
Baby's Date of Birth
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Day
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Month
Year
Date
How Many Weeks Gestation was Baby Born?
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Place of Birth
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Health Care Professionals
GP Name
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GP Address
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Street Address
Street Address Line 2
Town
County
Post Code
Midwife/Health Visitor Name
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Contact Details
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Consent
I Understand that:
All medical care is to be provided by my GP and Midwife or Health Visitor and any change from their recommendations should be discussed with them
A consultation with an IBCLC may include examination of the breasts, the baby's mouth, an observations of a breastfeed, demonstration of techniques and equipment to improve breastfeeding and a recommendation of a care plan to treat breastfeeding issues which may be adjusted over time.
Students may occasionally accompant the IBCLC, you will be advised of this and have the right to decline
I am responsible for informing the Lactation Consultant of any changes in the breastfeeding situation.
Payment for Lactation Consultant services and equipment are my responsibility and invoices will be paid promptly, a receipt will be provided.
I grant consent that:
Information about this consultation can be shared with my GP or other Health Care Professional
Information, photographs, and/or video from this consultation to be used for teaching purposes, with the understanding that no names or identifying features will be used.
Treatment will be given according to the scope outlines above.
Jenny Baldwin IBCLC can hold and process my data. Data will be stored securely until the baby reaches the age of 25, it will then be safely destroyed.
Jenny Baldwin IBCLC can contact me by phone or email for the purposes of following up on this consultation.
My Signature acknowledges my understanding of the above.
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