Contact

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Please read FEES AND SERVICES, INSURANCE, and WHAT TO EXPECT IN A CONSULT prior to completing this form. Thank you!

Indicate your preference for virtual or in-home visit: *

virtual visit home visit

Breastfeeding Parent Name *

First

Last

Breastfeeding Parent date of birth *

phone number *

Email *

Infant's Name *

First

Last

Infant's Date of birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

instructions on parking and building access *

Superbill for insurance? *

Name of Primary Insurance Subscriber *

First

Last

Date of birth of insurance primary subscriber *

insurance company & member ID *

Insurance group or plan number *

pediatrician name and contact information *

availability and schedule requests *

reasons for consult *

FOR FAMILIES REQUESTING HOME VISITS:

Have you or any member of your household had any of the following symptoms in the last 10 days?

Fever, night sweats, or shaking chills
Shortness of breath
Cough
Sore throat
Body aches
Loss of sense of smell or taste
Diarrhea
Rash
Positive test for COVID-19
Awaiting result for test for COVID-19

Choose One *

No, none of the above. Yes; I understand I need to discuss further with LC prior to scheduling.

Please indicate your agreement to the following safety practices: *

I will inform the lactation consultant prior to visit if any member of my household develops symptoms of illness. I will provide a space for lactation consultant to wash hands prior to beginning visit.

Please check *

I give permission for LC to communicate with my child's pediatrician. I have received this link for the standard privacy practices:

https://drive.google.com/file/d/1RB6FFsctRw28m2Z5DGEYuDVI8_iSR-Bn/view?usp=sharing

CONSENT FOR CARE

I understand that during a home or office visit for lactation support, Amanda Halpin, RN, NP, IBCLC will examine me and my breasts both visually and manually, will examine me and my baby or babies both visually and manually (including an oral exam with a gloved finger), 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 will provide Amanda Halpin, RN, NP, IBCLC with the names and contact information for other relevant healthcare providers for me and my baby, and Amanda Halpin, RN, NP, IBCLC may communicate with them. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for Amanda Halpin, RN, NP, IBCLC to send and receive texts and emails that may contain my Personal Health Information (PHI). 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 understand that if I include any third party on an email or text with Amanda Halpin, RN, NP, IBCLC, I am granting permission for Amanda Halpin, RN, NP, IBCLC to communicate my health information and that of my baby or babies with that third party. Amanda Halpin, RN, NP, IBCLC will not initiate inclusion of any third party on an email or text. I acknowledge that Amanda Halpin, RN, NP, IBCLC 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 Amanda Halpin, RN, NP, IBCLC’s payment policies (at "fees and services" page) and understand that I am responsible for all charges associated with this visit. Amanda Halpin, RN, NP, IBCLC is providing care to me and to my baby or babies; together we are all the clients of Amanda Halpin, RN, NP, IBCLC. Amanda Halpin, RN, NP, IBCLC may communicate with my insurance company in reference to the services provided to me and my baby or babies. Amanda Halpin, RN, NP, IBCLC 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 Amanda Halpin, RN, NP, IBCLC 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. I have received a copy of the Privacy Practices of Amanda Halpin, RN, NP, IBCLC.

Type your name here to serve as your signature on the consent form above: *

Submit

Fill out this form to request a consult.

Serving the San Francisco Bay Area