Client Intake Form
Please fill out the questionnaire below.
Client Intake Form - **Please Fill In Every Field**
Illness Policy during COVID-19
While virtual visits are the safest option in this time of social distancing, I will still do home visits when needed by following the British Columbia’s/Canada’s Health’s COVID-19 Guidance for In-Home Caregivers.
I do not do home visits if I have a fever, new respiratory symptoms like a new cough or sore throat, if I have had known exposure to someone with COVID-19 or other communicable illnesses, or if I have been diagnosed with COVID-19. It is important to point out that COVID-19 has a 14 day incubation period, which means that people who are not showing symptoms can still spread the disease.
During home visits I will do my best to maintain social distancing, however a lot of breastfeeding things do require me to be close enough to see what’s happening. I will wear a MASK during the entire visit, as well as washing/sanitizing my hands and my equipment. I do have a respiratory condition (just like asthma) that may make me cough at times, but I can assure you this is not associated with COVID-19.
By agreeing to my illness policy you are confirming that no-one in your household:
- Has a fever (Higher than 100.3 degrees) or new respiratory symptoms such as cough, shortness of breath, or sore throat
- Has any flu-like symptoms
- Has travelled to a COVID-19-affected area (outside of U.S.) in the past 14 days
- Has had contact with a person diagnosed with COVID-19 in the past 14 days
- Has been diagnosed with COVID-19 or told by a healthcare provider that they may or do have COVID-19
I will also contact you before the visit to double check that we are all still healthy and ready to meet! We can always switch from a home visit to a virtual visit (as long as I have at least 4 hours notice before our appointment- otherwise we can reschedule to an virtual visit at a different time). I will refund any deposit paid if we cancel due to illness.
Consent For Feeding Consultation Services
I grant my permission for feeding consultation services to be performed by the undersigned lactation consultant. I understand that to learn how the feeding consultant can help me, this consultation may consist of the following: a medical history of me and my baby, a physical assessment of my breasts | chest, an assessment of how my baby feeds at the breast | chest or by bottle including an examination of his/her mouth and tongue, the use of feeding aids and equipment, helpful hints and other educational information to help me feed at the breast | chest.
I authorize the lactation consultant to release the information gained from the consultation to my primary care physician(s), health care provider and insurance company (to assist with claim reimbursement). Optional: During the consultation, I would like my husband/support person to photograph this session for my personal use. I understand that these photos or videos are not to be sold, shared or released on the internet. The lactation consultant agrees to be photographed or videoed for my own teaching purposes only.
I understand that all medical care for my baby and I is to be provided by our physician(s), midwife(s) or pediatrician(s).I understand and agree the information in this file will be kept for a period of seven years and protected by the HIPPA Act.
I accept payment responsibility for the lactation consultation, and/or purchase of supplies, regardless of insurance or other third-party involvement. I authorize the undersigned consultant to charge for my services rendered. The fee for services is as followed: Home visits- $175 (up to 120 mins), follow up visit is $160. Clinic visits- $160 at the Surrey Location, $150 for the Chilliwack location (120mins), Latch clinic-$135 (60 min) Packages will be discounted accordingly. A 2-week support continues via phone, text, or e-mail. Virtual visit-$160, Telephone consultation -$65. Cancellations made with less than 12 hours’ notice are subject to a $50 fee.
Receipts are available upon request which can be submitted to extended benefits if available to you. Submission will be the responsibility of the client. Payment is accepted by Debit, Credit Card and Cash.