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Mother and Baby on Floor

Kristen Kratz Lactation Care LLC Consent Form

I understand that during a home or office consult or subsequent follow up visits for lactation support, Kristen Kratz (RN IBCLC) will review me and my baby or babies medical history, will examine me and my breasts both visually and manually, will examine me and my baby or babies both visually and manually (including an oral exam with a gloved finger), will observe baby or babies at rest on back/on tummy/being held, will observe me and my baby or babies while breast or bottle feeding, will observe a pumping/hand expression session, may use scale to weigh baby or babies and/or assess milk transfer during feed, will make clinical observations, will provide information on breastfeeding techniques and breastfeeding equipment, factors impacting successful breastfeeding/bottle feeding/typical milk production and will make recommendations towards helping me reach my breastfeeding/lactation goals. I understand no outcome can be guaranteed.

I will provide Kristen Kratz with the names and contact information for other relevant healthcare providers for me and my baby or babies. Kristen Kratz may communicate with them, this includes but is not limited to; baby or babies pediatrician, mother’s OB/GYN or primary care physician. If needed information may be shared with other medical offices/practitioners including but not limited to; pediatric dentist, ENT, chiropractor/body work specialist, OT, PT, etc.

It is my responsibility to provide accurate information and to keep it updated. I understand that emails and texts are not secure means of communication, and give my permission for Kristen Kratz to send and receive texts and emails that may contain my Personal Health Information (PHI) and if I choose to communicate via text or email, I am doing so with this understanding. Because Kristen Kratz may be coming to my home, I grant permission for Kristen Kratz to give my address to her spouse for safety purposes and I understand that Kristen Kratz will use GPS to navigate to my home.

(Office visit only) I understand that if I am late to an office appointment Kristen Kratz has the right to reschedule my appointment automatically for a later date in order to be respectful of other clients' appointment times. 

I understand that if I fail to complete all the appropriate paperwork/intake forms or provide all requested information listed in intake forms that my appointment will be canceled automatically.

I understand that if my insurance company denies a claim fully or partially or refuses to process a claim that I am responsible for all payments due to Kristen Kratz Lactation Care LLC.

I understand that it is my choice to have someone else present during the visit, and that anyone who sits in on the visit will have access to my healthcare information and my confidentiality may not be guaranteed. I understand that if I include any third party on an email or text with Kristen Kratz, I am granting permission for Kristen Kratz to communicate my health information and that of my baby or babies with that third party. I acknowledge that Kristen Kratz is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party to text or email.

I have read and reviewed Kristen Kratz’s payment policies and understand that I am responsible for all charges associated with this visit. Kristen Kratz is providing care to me and to my baby or babies; together we are all the client of Kristen Kratz. Kristen Kratz may communicate with my insurance company in reference to the services provided to me and my baby or babies. Kristen Kratz may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information.

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