Baby Hippie Inc is providing care to me and to my baby or babies; together we are all the client of Baby Hippie Inc.

I understand that during a consult for lactation support, a Baby Hippie Inc IBCLC will examine me and my breasts/chest both visually and manually, will examine me and my baby or babies both visually and manually, will observe me and my baby while feeding, will make clinical observations, will provide information on techniques and breastfeeding equipment, and will make recommendations towards helping me reach my breastfeeding goals. I understand no outcome can be guaranteed. I give my consent to undergo such examination and assessment and know that I can withdraw my consent at any time and that I am free to bring an additional person to any session to act as my advocate. 

This will be discussed with you further, prior to your examination and a Baby Hippie Inc IBCLC will discuss any questions you may have regarding the exam. 

Baby Hippie Inc will protect my personal information using secure accounts that comply with all applicable privacy laws. Baby Hippie Inc will provide me with policies and procedures related to the protection of personal information upon receipt of a written request.

I will provide Baby Hippie Inc with the names and contact information for other relevant healthcare providers for me and my baby, and I authorize Baby Hippie Inc to share my information as deemed necessary. I also understand that my personal and medical information is confidential and will only be disclosed to third parties (including medical doctor and healthcare providers) with my permission. 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 Baby Hippie Inc 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 Baby Hippie Inc, I am granting permission for Baby Hippie Inc to communicate my health information and that of my baby or babies with that third party. Baby Hippie Inc will not initiate inclusion of any third party on an email or text. I acknowledge that Baby Hippie Inc 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 Baby Hippie Inc’s payment policies and understand that I am responsible for all charges associated with this visit. Baby Hippie Inc may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment information.