Consent for Care for Dream Baby Sleep Lactation

I understand that during a virtual consult for lactation support, Nannie Reinert, Certified Lactation Educator may examine me and my breasts visually, may examine me and my baby or babies visually, may observe me and my baby while feeding, may make clinical observations, may provide information on techniques and breastfeeding, pumping, and feeding equipment, and will make recommendations towards helping me reach my goals. Nannie Reinert will guide me in positioning my camera to be able to see me and my baby, and will direct me in assessments of my breasts and/or my baby in the furtherance of my care.

I understand no outcome can be guaranteed. I acknowledge that there may be some limitations with virtual care.

I will provide Nannie Reinert with the names and contact information for other relevant healthcare providers for me and my baby, and Nannie Reinert may communicate with them. It is my responsibility to provide accurate information and to keep it updated.

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 have provided written notice to Nannie Reinert of any person(s) I wish to have present during the visit. I understand that if I include any third party on an email or text with Nannie Reinert, I am granting permission for Nannie Reinert to communicate my health information and that of my baby or babies with that third party. Nannie Reinert will not initiate inclusion of any third party on an email or text. I acknowledge that Nannie Reinert 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 Nannie Reinert’s payment policies and understand that I am responsible for all charges associated with this visit. Nannie Reinert is providing care to me and to my baby or babies; together we are all the client of Nannie Reinert. Nannie Reinert may communicate with my insurance company in reference to the services provided to me and my baby or babies. Nannie Reinert 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.

I give permission to Nannie Reinert to photograph or record video of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my baby’s healthcare team.

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