Consent Form

Lactation & Massage Consent Form

Birth and Breastfeeding Solutions
Julie L. Johnson, BA, IBCLC, RLC, LMT • International Board Certified Lactation Consultant and Licensed Massage Therapist #259785-4701
495 E. 4500 S. #105, Murray, UT 84107

RELEASE / CONSENT FORM

A lactation consultation includes visual and physical assessment of the mother’s breasts, visual and physical assessment of the infant’s mouth, such as; range of motion of lip and tongue, range of motion of neck and misalignment in relation to breastfeeding. Observation of the mother and infant nursing, analysis of the data relating to the breastfeeding situation, demonstration of techniques for improving breastfeeding, and sometimes the use of breastfeeding equipment. I give permission for the lactation consultant to do all of the above.

I understand that all medical care is to be provided only by our physician(s). I give my permission for information about this and all additional consultations to be sent to my attending physician(s)/ health care provider(s). I give my permission to have my case be discussed with lactation
educators and/consultants for learning purposes and/or further appropriate plan of care.

I understand that payment is due before or at the time services are rendered. I give my permission for information to be released to my insurance company to assist in evaluation of an Aetna only claim. I understand that there is a 24 hour cancellation policy.

I give permission to Julie Johnson to photograph or videotape myself and/or my infant(s). I acknowledge that these images belong to Julie Johnson and that she intends to use these images for the purpose of education and the promotion of breastfeeding and lactation counseling.

I give my permission for Julie Johnson, LMT to touch and provide breast massage specific to Lymphatic Drainage as specifically trained in additional Lymphatic education she has received. This would be for engorgement, edema or any other reasons to help reduce congestion in the breast tissue. I give her permission to provide oral Lymphatic drainage to help organize my infant’s suction and clear sinuses. I understand that Lymphatic drainage may also be used to reduce the swelling of a hematoma on the head due to any birth trauma.

I understand that I have the right to refuse any or all specific techniques suggested, equipment to assist or remedy breastfeeding problems, and/or all recommended actions.

 Julie Johnson has the right to terminate a professional relationship with a client at any time and will provide names of other qualified providers when necessary.

Print________________________________________Signature______________________________

 

Date_____________________________