I have requested assessment and/or treatment by this International Board Certified Lactation Consultant (IBCLC) Sierra Killam. I understand that this includes the clinically relevant areas of my breasts, nipples, axilla, and the structures inside my baby’s mouth.
The IBCLC will explain the following to me and I will be able to ask questions to fully understand the proposed assessment and/or plan:
• The nature of the assessment, including the clinical reason(s) for assessment of the above area(s)
• The expected benefits of the plan
• The potential risks of the plan
• Possible alternatives to the plan
• That consent is voluntary
• That I can withdraw or alter my consent at any time.
I voluntarily give my informed consent for the assessment, treatment, and/or plan as outlined above.