Please enable JavaScript in your browser to complete this form.Birth Parent Full Name *Please indicate your preferred name and your pronouns (she/her/ they etc).Name of supporting person also present in the consultationName of partner, dad, supporting adultIf you have any additional needs, please let me know, and I will do what I can to help you during the consultation.For example: Physical disability or neurodiversity. (Dyslexia, ADHD etc) Baby full name *Please enter your own if baby doesn’t yet have a nameEmail *Mother date of birth *Baby date of birth *Baby current age *Baby Sex *FemaleMaleHow long do you plan to breastfeed for?How did you find out about my services? *Contact number *Home Address *Please include postcodeHospital used for birth *Or hospital to report to if you had a home birthMidwife or health visiting team *Method of birth *Please also list here if you received fluids and medication/pain relief during birth.Length of labour *How many weeks gestation was baby at birth? *Per 24 hours, how often if your baby feeding? *0-8 times8-12 times12-20 timesNot currently breastfeedingPrevious breastfeeding experience? *Yes, successfulYes, with problemsNoDoes your baby have any weight related concerns? *YesNoIf yes, please give description below. Include all weights recorded from birth with dates in Kg. If yes, please give a descriptionIs birth parent or baby taking any medication, including in the past week?Please indicate who and what.Has the birth parent had any surgery or biopsy of their breast/chest?Any health concerns related to birth parent or baby?How is baby currently being fed? *Exclusive breastfeedingBreast milk in a bottleBreast milk from a feeding deviceBreast milk and formula milkExclusive formula milkOtherPlease indicate preferred upcoming date for appointment. *This is dependent on Sophie’s availability. There are occasions that Sophie might be able to see you within hours of your booking request so please indicate your next available time. Please let me know if you have any pets *(I have allergies so need to prepare in advance)Please let me know of any parking information and if your home is hard to find, key information for how to find it. *Clients are required to pay and parking chargesHave you had a consultation with an IBCLC before? *YesNoIf yes, please give some information as to why. *Please give a description here of the reasons you are requesting a consultation. *Please indicate anything you’ve already tried.Please indicate any additional questions here. This service is £100 + Travel . I will send you an invoice before the consultation. The consultation is an in-depth overview of the situation, the consultation can take over an hour and I don’t time myself; I am here to support you and sometimes that can take time. I will do a written report after to send you with links to your particular situation to support you with the issues you are experiencing. On average I spend 4+ hours per client with report writing, ongoing support etc. Payment is due before the consultation can commence. Thank you for your understanding. *Understood and AgreedIn accordance with GDPR 2018 you must be informed what Data will be requested from you, how that Data will be processed or shared and what your rights are in relation to that Data. I will only request information that she needs in order to provide her services effectively and safely. I will retain your consultation Data for a period of 25 years as per Government requirements. Your information will not be used for marketing purposes. The Data held about you will include name, age, address, email, your child’s name and date of birth, medical history, consultation notes, and may include a baby’s weight chart, care plan and a report to your GP. Information may be shared with your health professionals (see above). You have the right to request access to your personal Data. You also have the right to correction of that Data and deletion (where appropriate). If you are not happy with how your Data is managed, you have a right to complain. I reserve the right to contact you in the future regarding other services *AgreedOur Contract: I am requesting and give consent for a breastfeeding consultation with an International Board Certified Lactation Consultant for myself and my infant/s. The consultation will include but not be limited to a visual examination of my breasts as well as an observation of a breastfeeding session. While advice given by Lactation Consultants is effective in most instances, I understand that these recommendations may not completely remedy or prevent adverse symptoms. The success depends, in larger part, on my follow-through with the recommendations. • I understand that a partial or follow-up visit/call is sometimes necessary. • I understand this consent it for in-person visits, as well as phone conversations, and any information sent/ communicated by e-mail, mobile phone, fax, SMS text messages, and/or private social media. I understand electronic/ cellular forms of communication may not be encrypted/ secure. • I understand that breastfeeding supplies and/or breast pumps may be recommended as effective management of specific situations. • I understand that my doctor is my primary health care provider and that he/she is responsible for the overall care of my infant/s. I will receive written recommendations at the end of this visit. A copy of the recommendations may be sent to my doctor for his/her information. I indicate with my agreement below that I agree to this. • I give consent for the lactation consultant to use clinical information and any photographs obtained during our sessions for conferring with other health care providers and education of mothers about lactation. I won’t be identified in any way, but aspects of my situation may be described and discussed. • I understand it is my responsibility to call/ communicate to the lactation consultant with progress reports, questions or concerns. • I understand that charges for this consultation will be payable in a timely manner when requested by the lactation consultant • I understand that for this lactation consultation and all follow-ups, the lactation consultant will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners and the Standards of Practices of the International Lactation Consultant Association. • I understand that the Lactation Consultant may be interrupted during any consultation and that they have a young family and may need to answer the phone during a consult but the lactation consultant will strive to make that as unlikely as possible but when agreeing to book a consultation I understand this is a possibility. *AgreedPhoneSubmit954
