Name *

First Name

Last Name

Consent Form *

I understand that this support group is meant to provide me with information and education. Participation in this group does not create a clinical relationship between me and Milk Coach Lactation LLC.. I understand that I am responsible to consult with my primary care provider and/or my baby’s primary care provider before taking action on anything that happens here today. I recognize that Milk Coach Lactation LLC. is not a doctor and cannot provide medical advice or supervision. I recognized that if I have an established clinical relationship with Milk Coach Lactation LLC. as my lactation consultant, it is up to me what I wish to share in the group setting about our prior clinical relationship. If I do reveal a clinical relationship, I understand that Milk Coach Lactation LLC will not make reference to our private clinical conversations in the group context, and will not provide me with specific or personal clinical recommendations or a plan of care. I give permission to Milk Coach Lactation LLC to examine me, my breasts, and my baby visually and manually. I may withdraw this consent at any time.

Agree