The Latch and Learn Breastfeeding Drop in Clinic is a service of 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). Lactation Consultant services are provided by Pastor Angelique RN,MSN, International Board Certified Lactation.
I understand the Breastfeeding Drop in Clinic service is conducted by a Lactation Consultant with Precious Jewels Moms Ministries who is also an Ordained Pastor/ Chaplain.

I understand the Breastfeeding Drop in Clinic service is provided by Precious Jewels Moms Ministries, a Christian non for profit. Therefore, I will be offered optional prayer, baby blessing and other religious sacraments at the conclusion of the breastfeeding service.  This is optional and one may decline.

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

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

I understand that a lactation consultation may involve: touching my breasts and/or nipples for the purposes of assessment;
                * inserting gloved fingers into my baby's mouth to assess suck and oral cavity;
                * observation of a breastfeed, and suggestions to enhance latch or positions;
                * demonstration of the use of equipment or supplies that may be recommended and
                * demonstration of techiques designed to improve breastfeeding
                
             *Baby must be present

                * Baby should be ready to breastfeed at time of appointment 

I understand this Breastfeeding Drop in Clinic/Lactation Consultation is intended to be a quick fix to common breastfeeding difficulties seen in the first 2-3 weeks such as difficulty latch,  evaluation of infant milk intake and weight gain or loss.

I understand this Breastfeeding Drop in Clinic/Lactation Consultation session will last approximately 20 to 30 minutes. If, 30 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 the Breastfeeding Drop in Clinic/Lactation Consultation is a 20-30 minute individual session requires no charge and is therefore free for mothers on the Women Infant and Nutritional program (WIC) during the reserved time slot.

I understand the Breastfeeding Drop in Clinic/Lactation Consultation Fee for service is 45 minute individual session that requires a charge of $45.00 for mothers who are NOT on the Women Infant and Nutritional program (WIC) at the  reserved time slot. If, a return visit is required an additional fee is required.

I understand if I am NOT a WIC mother total payment is expected at the conclusion of the consultation cash or electronic payment. I will receive an invoice to submit to my insurance company for consideration of reimbursement.

I understand this Breastfeeding Drop in Clinic/ Lactation Consultation is NOT for complex breastfeeding difficulties such a poor infant weight gain, low milk supply, difficulty latch beyond week 3. A referral to an outside Lactation Consultant will be given.

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

I understand a student may be present for observation and teaching purposes.

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 Lactation Consultant Association, and the Health Insurance Portability and Accountability Act of 1996 (HIPPA). *
If the Client agrees with above, please sign; *
clear
Reservation Time Slot *
Reservation Time Slot *
Delivery Type *
Were you induced *
Mark All that Apply *
                                      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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The Latch and Learn Breastfeeding Drop in Clinic is a service of 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). Lactation Consultant services are provided by Pastor Angelique RN,MSN, International Board Certified Lactation.