Consent to Treat

By filling out this form I give my consent for Anne-Marie Sandoval BSN, RN, IBCLC to work with me and my baby during this Lactation Consult and any follow-up, either in person or via email or text.

First name

Last name

Email

Date of Birth

I understand that this consultation does not supersede routine weight and wellness checks with my child’s pediatrician.

I understand follow-up with my child’s pediatrician is advised for any changes in feeding pattern, feeding quality, concerns for poor feeds, or concerns for illness.

I understand it is my responsibility to call the Lactation Specialist with progress reports, questions or concerns

I understand that for this lactation consultation and all follow-ups, the Lactation Specialist will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners, and the Standards of Practice of the International Lactation Consultant Association.

I understand that payment is due at time of service and that reimbursement is not guaranteed.

I understand that it is my responsibility to pursue reimburment through my insurance company and AnneMarie Sandovl IBCCL LLC does not guarentee reimburment in any form.

Initials

Thanks for submitting!

Baby's Information

Please fill out this quick intake 24 hrs prior to your first consult. Thank you!

Maternal Information

Consent to Treat