Faith Based Lactation Telehealth Consult- is a service of Precious Jewels Moms Ministries(tm)
provided by Pastor Angelique MSN,RN,International Board Certified Lactation Consultant
Faith Based Lactation Telehealth Consult-
Brief Lactation Telehealth consultation for lactation/breastfeeding support or non-clinical issues  that 
do not require a feeding or latch evaluation or infant weight check.

I give my consent for the lactation consultant to work with me and my baby during this brief
Lactation Telehealth consultation for my breastfeeding problem/concern.

This consent is for Lactation Telehealth support, phone conversations, and information
sent by e-mail, fax, or text, and includes appropriate follow-up contact.

I understand this Lactation Telehealth consultation may not be appropriate for issues 
requiring a feeding or latch evaluation or infant weight check.
I understand this Lactation telehealth is intended to be a quick fix to common
breastfeeding misunderstandings seen in the first 2-3 weeks.
This Consultation is for one breastfeeding concern and up to three
questions related to that breastfeeding concern.

I understand the Lactation Telehealth Consultation charge is covered by the COVID-19 Relief grant for families of color. Therefore, this time YOU WILL NOT BE  ask that you select a workable donation amount for your family,
remembering that this donation helps our organization to continue to our programs and
services to the community.
I understand the Lactation telehealth session will last approximately 20 to 60 minutes.
If, 60 minute time frame has been reached I understand I will have to reserve the next
available time slot. I understand this is an individual breastfeeding session.

I understand that Precious Jewels Moms Ministries Lactation Telehealth Consultation is a
faith based service. Therefore, spiritual guidance related to the being a wife/mothering, prayer
mother/baby blessing and other religious sacraments are available.

I give my consent for the Lactation Consultant to use clinical information during our sessions for
education of other health care providers. I will not be identified in anyway, but aspects of my
situation may be described and discussed.

I give permission for photographs and audio and/or visual recording to be made of both
my baby and me for charting and clinical/education purposes.If, photographs are share
in a clinical or educational context identifying features or information will not be shown.

I understand that this lactation consultation and all follow-up, the lactation consultant will protect
the privacy of my personal health information as required by the Code of Ethics of International
Board of Lactation Consultant Examiners, the Standards of Practice of the International
LactationConsultant Association, and the Health Insurance Portability and
Accountability Act of 1996 (HIPPA).
If the Client agrees with above, please sign; *
COVID-19 Birth worker of Color Relief Fund Reservation Time Slot Lactation Health Session
COVID-19 Birth Worker Relief Fund Reservation Time Slot Economic Hardship Lactation Health One Session
Delivery Type *
Were you induced *
Mark All that Apply *
Spiritual Guidance Request *
                                      Infant Health

Did baby have any of the following during or after birth? *
# of Wet Diapers in past 24 hours *
# Stool Diapers in past 24 hours *
Have you needed to supplement? *
Have you pumped? *
Maternal History

Is this your first baby?

Did you breastfeed your other babies?
Check all of the following that apply to your medical history *
Labor and Delivery

Did you have any of the following in labor *
Breastfeeding History

Did you notice breast change first trimester? *
Is your milk in yet? *
Did the baby need to be supplemented in the hospital? *
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Precious Jewels Moms Ministries(tm)  501(c)3 non profit incorporated in the State of Illinois
Vision: Nursing Mothers Raising Children with Generational IMPACT(tm).