Consent Form & Contract

Jasmine Kelly, IBCLC Lactation Consultant. Jennifer michel IBCLC,RN. Gemma Gaunt RN, breastfeeding specialist, Essex. littlelatcher@gmail.com littlelatcher.co.uk 07398710539

I understand that any consultation may involve a visual observation and manual examination of my baby, my baby’s mouth and my breasts. It will also involve a member of the little Latchers team observing me feeding my baby.

I understand that it may be necessary for information from this and any subsequent consultation to be shared with my health provider (which may include my GP, health visitor, midwife or any other health professional I or my baby are currently in the care of or may be in the future. My IBCLC may legally be required to share relevant information to the authorities for safeguarding purposes.

I understand that it may be necessary for information from this and any subsequent consultation to be shared for referral to relevant healthcare professionals (which may include Tongue Tie Service Providers)

I am aware that payment is due prior to or at the time of the consultation and that the payment is for services rendered. Some breastfeeding problems are complex and take time to resolve and sometimes this may require more than one consultation.

Details of my situation may be shared anonymously with other lactation professionals where necessary. No identifying information will be shared.

(Sometimes even a very experienced IBCLC will seek to inform her practice by asking for input from other IBCLC’s.)

I am aware that my IBCLC may/will use my contact information to contact me by phone, email or letter to provide relevant information, follow up information, ongoing support & for audit purposes.

Informed consent. I have the right to discuss and refuse any of the above and also the right to refuse any techniques or equipment discussed during the consultation. The IBCLC, Jasmine kelly/Jennifer michel/Gemma Gaunt aims to find a solution that is right for me and my baby based on the information I provide and agree to.

I have read and understood the above and I give my informed consent for the consultation

Data Protection Consent Form & Contract

In accordance with General Data Protection Regulations 2018 (GDPR) you must be informed of what Data will be requested from you, how that Data will be processed or shared and what your rights are in relation to that Data. Jasmine Kelly will be both the Data Controller and the Data Processor, solely responsible for your privacy. She will only request information from you that she needs in order to provide her services effectively and safely for legal, contractual and legitimate reasons. She will retain your consultation Data for a period of 25 years as per Government requirements. Your information will not be used for marketing purposes.

The Data held about you may include name, age, address, email, your child’s name, date of birth & NHS number (on occasion for medical referrals or communication with other health care professionals), medical history (including obstetric and breastfeeding history), consultation notes, baby’s weight chart, care plan, report (may include a report to your GP

Information may be shared with your health professionals (see above

You have the right to request access to your personal Data that is held and be provided with that Data free of charge within a month of your request. You also have the right to correction of that Data and deletion (where appropriate If you are not happy with how your Data is managed, you have a right to complain to the Information Commissioners Office (www.ICO.org.uk All of your Data is processed by Jasmine Kelly using:

• - Paper for the medical history and consultation notes (secured in a locked cabinet)
• - Password Protected Email for medical reports & follow up information
• - Password protected computer for storage of electronic records including weight charts,

invoices, referral letters, follow up plans & photos

• - Phone – fingerprint, face ID and passcode protected

NOTE Whilst I, the IBCLC take steps to ensure your information is secure communications by text, email, messenger, social media, WhatsApp may not be secure so keep this in mind when using these methods.

I have read and understood the above and I give my informed consent