Consent for Care

Lactation Consultation Consent for Care

I give my consent for Rosamund Se, a certified Advanced Lactation Specialist, to provide lactation care for myself and my baby. Together, myself and my baby are both the clients of Rosamund Se at Milk Clinic LLC. This consent covers any communication via in-person visit, video-call, phone, text, email or secure messaging. 

Telehealth Video Consulations

  1. I understand that during a virtual consult for lactation support, Rosamund Se may:

  •  examine me and my breasts visually

  • examine me and my baby or babies visually

  • observe me and my baby while feeding

  • guide me in positioning of my camera to be able to see me and my baby

  • direct me in physical assessments of my breasts and my baby for the furtherance of my care

  • make clinical observations

  • provide information on breastfeeding, pumping, and feeding related equipment, supplies and techniques

  • make recommendations towards helping me improve breastfeeding and reach my goals.

2. I understand if I am unable to access Rosamund Se's secure video platform Google Hangout Meets, we may use the non-HIPAA compliant platform of my choice, as long as it is private.

3. I understand that there may be some limitations with virtual care. 

In-Person Home Visit Lactation Consultations

  1. I understand that during an in-person consult for lactation support, Rosamund Se may:

  • examine me and my breasts visually

  • examine me and my baby or babies visually

  •  touch me and my breasts during physical assessments of me and my breasts

  • touch my baby or babies during physical assessments (including an oral exam with a gloved finger)

  • observe me and my baby while feeding

  • make clinical observations

  • provide information on breastfeeding, pumping and feeding related techniques, equipment and supplies

  • make recommendations towards helping me reach my breastfeeding goals

General Care

  1. I understand no outcome can be guaranteed and a follow-up or referral may sometimes be necessary

  2. I will provide Rosamund Se with the names and contact information for other relevant healthcare providers for me and my baby, and Rosamund Se may communicate with them. 

  3. It is my responsibility to provide accurate information and to keep it updated

  4.  It is my responsibility to inform Rosamund Se of any progress, questions, concerns or change to my care plan at the time of consultation or during follow-up communications

  5. I understand any recommendations differing from my primary care provider or physician’s recommendations should be discussed with the physician. Medical conditions are beyond the scope of an Advanced Lactation Specialist and must be discussed with a physician.

  6.  I understand that email and text are not secure means of communication

  7. If I initiate contact via text or email I give my permission for Rosamund Se to send and receive texts and emails that may contain my Personal Health Information (PHI)

Third Parties

  1. I understand that if I include any third party on an email or text with Rosamund Se, I am granting permission for Rosamund Se to communicate my health information and that of my baby or babies with that third party. Rosamund Se will not initiate inclusion of any third party on an email or text.

  2.  I understand that it is my choice to have someone else present during the consultation, and that anyone who sits in on the consultation will have access to my healthcare information and my confidentiality may not be guaranteed. I have provided written notice to Rosamund Se of any person(s) I wish to have present during the visit.

  3. I acknowledge that Rosamund Se 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. 

  4.  If I have a home visit, I grant permission for Rosamund Se to give my address to Kenneth Se for her personal safety, and I understand that Rosamund Se will use GPS to navigate to my home.

  5. I understand that Rosamund Se is providing lactation care within the scope of an Advanced Lactation Specialist and not an IBCLC. 

  6.  I understand consultations provided by Rosamund Se are clinically supervised by IBCLC mentors under the Liquid Gold Concept Pathway 3 Progam. I give my consent for Rosamund Se to communicate and share personal health information and photographs with her IBCLC mentor in accordance with HIPAA compliance and data privacy for the purpose of clinical supervision and professional training. 

  7. I have read and reviewed Rosamund Se’s payment policies and understand that I am responsible for all charges associated with this visit. Rosamund Se is providing care to me and to my baby or babies; together we are all the client of Rosamund Se. Rosamund Se may communicate with my insurance company in reference to the services provided to me and my baby or babies. Rosamund Se 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. 

  8.   I give permission to Rosamund Se 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. 

Last reviewed on 3rd January 2022.