Lactation & Massage Consent Form

Birth and Breastfeeding Solutions
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Julie L. Johnson, BA, IBCLC, RLC, LMT, CST • International Board Certified Lactation Consultant, Licensed Massage Therapist, Certified Craniosacral Therapist #259785-4701
3115 Lion Ln E, Suite 310, Holladay, UT 84121

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 dyad 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 other 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 or Liberty Health Share only claim. I understand that there is a 24 hour cancellation policy and a $50.00 cancellation fee.

I give my permission for Julie Johnson, LMT, CST 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 also give permission for my baby to receive craniosacral therapy as needed.

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