Client Intake Form
Please fill out the questionnaire below.
Client Intake Form - **Please Fill In Every Field**
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.
If your household has any of these symptoms, a 4 hour notice of cancellation is required-
-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 been diagnosed with COVID-19 in the past 5 days or remains to have symptoms.
-The Lactation Consultant is also required to inform your family of any symptoms with herself or in her household and will reschedule at no added charge. Please be aware the Lactation Consultant has a respiratory condition that may present as a cough, but you can be assured she is not sick.
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 also agree to receive communication via email/text/phone for further support. I understand this form of communication may be insecure and will not be shared with other parties.
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- $210 (travel fee added depending on location) Chilliwack Office $175, Surrey Latch clinic visits- $175. Virtual visit-$125, Telephone consultation -$125.
Cancellations made with less than 12 hours’ notice are subject to a $50 fee. Twins will be an added $50 to the above prices. Phone support continues for 2 weeks after the consultations.
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.