Consent for Care

Please be assured that although the consent form does ask you to grant the below permissions, I also always ask in person before touching you or your baby, taking photos, or recording anything. All of these permissions are asked to provide you with the best care possible.

If you have any questions about the following, I am happy to discuss anything in further detail.


I understand that during a consult for lactation support, Kristin Szerszen, CLC, Emily Martin, IBCLC, Danielle Henderson, IBCLC, Jo Anna Curless, RN, IBCLC, or Connor Giddens, CLC ("the provider") will examine me and my breasts both visually and manually, will examine me and my baby or babies both visually and manually (including an oral exam with a gloved finger), will observe me and my baby while feeding, will make clinical observations, will provide information on techniques and breastfeeding equipment, and will make recommendations towards helping me reach my breastfeeding goals. I understand no outcome can be guaranteed.

I will provide Milk Guide Lactation LLC with the names and contact information for other relevant healthcare providers for me and my baby, and the provider may communicate with them. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for the provider to send and receive texts and emails that may contain my Personal Health Information (PHI).

Because the provider will be coming to my home, I grant permission for the provider to give my address to her spouse, and I understand that the provider will use GPS to navigate to my home.

I understand that it is my choice to have someone else present during the visit, and that anyone who sits in on the visit will have access to my healthcare information and my confidentiality may not be guaranteed. I have provided written notice to the provider of any person(s) I wish to have present during the visit. I understand that if I include any third party on an email or text with the provider , I am granting permission for the provider to communicate my health information and that of my baby or babies with that third party. the provider will not initiate inclusion of any third party on an email or text. I acknowledge that the provider is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party to text or email.

I have read and reviewed Milk Guide Lactation LLC’s payment policies and understand that I am responsible for all charges associated with this visit. The provider is providing care to me and to my baby or babies; together we are all the client of the provider. The provider may communicate with my insurance company in reference to the services provided to me and my baby or babies. The provider may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information.

I give permission to the provider to photograph or record video of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my baby’s healthcare team.