Intake Form Mother's name (first last) Partner's name (first last) Mother's DOB Street address City State Zip Phone number Email Referred by Location of delivery Obstetrician or Midwife name Obstetrician or Midwife phone Obstetrician or Midwife fax Birth parent's occupation Infant's name (first middle last) Infant's DOB Infant's Due Date Infant's physician Infant's physician phone Infant's physician fax Infant's birth weight (example: 7lbs 5oz) Discharge weight (example: 7lbs 5oz) Discharge date Follow-up weight (example: 7lbs 5 oz) Follow-up Date Please tell me about your concerns and how I can help. Insurance company name Consent for Care and Treatment: I hereby give my written consent for Kate Ogilvie, IBCLC to work with my baby and myself during this and subsequent consultations for my breastfeeding problems/concerns. I understand that this consultation may involve touching my breasts and/or nipples for the purposes of assessment, performing an oral digital examination on my baby in order to assess the suck, observation of a breastfeed, and demonstration of use of equipment and techniques that may be necessary to improve breastfeeding. I understand that the Kate Ogilvie Lactation Consulting, Inc. SARS-CoV-2 or Covid -19 Safety Policy allows no more than one adult to be present as a supporter/helper for mom and baby during an in-home consultation. Other children in the home should remain in a separate room cared for by another adult if needed. I understand that all present (except infant) may or may not choose to wear a mask during the entirety of the time while the consultant is in your home. The IBCLC will be masked and will take every reasonable precaution to maintain a safe environment. IBCLC will leave as much equipment as possible near the door, bringing only what is needed into your home. IBCLC will wash their hands when arriving. IBCLC will provide hands-on help with the baby at the breast as needed and will address your breastfeeding challenges and questions. I understand I need to inform KO Lactation if anyone in my home, including myself, has any signs of illness prior to the consultation or if anyone in my home, including myself has recently been exposed to a person with known Covid-19 infection. The Kate Ogilvie Lactation Consulting, Inc. cannot be held accountable for the transmission of any disease or illness I give my consent for the LC to send any and all pertinent information to my infant’s and my primary health care providers, and to consult with them in any way she deems appropriate including electronic transmission of such information. I give my consent for the LC to release pertinent information to my insurance company as necessary. I give my consent for the LC to use clinical information obtained during these sessions for education of other health care providers or mothers about lactation. Information used in this way will not contain my name or my baby’s name but aspects of my situation might be described or discussed. I understand that total payment is expected at the conclusion of the consultation unless prior arrangements have been made. I further understand that I will receive appropriate forms that can be submitted to my insurance company for reimbursement. I understand that Kate Ogilvie Lactation Consulting Inc. will protect the privacy of my personal health information as required by the Code of Professional Conduct of the International Board of Lactation Consultant Examiners (IBLCE), the International Lactation Consultant Association (ILCA) Standards of Practice and in compliance with the Federal Health Insurance Portability and Accountability Act of 1996(HIPAA). I give my consent to receive emails or phone calls from Kate Ogilvie Lactation Consulting Inc. from time to time regarding information, a product, service or survey that may interest me. I acknowledge that I have had full opportunity to discuss and understand information and treatment options provided by the Lactation Consultant. I understand that I have the right to refuse any or all specific techniques or treatments suggested, and any or all equipment provided or recommended to assist or remedy breastfeeding problems. Consent for Care and Treatment: I hereby give my written consent for Kate Ogilvie, IBCLC to work with my baby and myself during this and subsequent consultations for my breastfeeding problems/concerns. I understand that this consultation may involve touching my breasts and/or nipples for the purposes of assessment, performing an oral digital examination on my baby in order to assess the suck, observation of a breastfeed, and demonstration of use of equipment and techniques that may be necessary to improve breastfeeding. I understand that the Kate Ogilvie Lactation Consulting, Inc. SARS-CoV-2 or Covid -19 Safety Policy allows no more than one adult to be present as a supporter/helper for mom and baby during an in-home consultation. Other children in the home should remain in a separate room cared for by another adult if needed. I understand that all present (except infant) may or may not choose to wear a mask during the entirety of the time while the consultant is in your home. The IBCLC will be masked and will take every reasonable precaution to maintain a safe environment. IBCLC will leave as much equipment as possible near the door, bringing only what is needed into your home. IBCLC will wash their hands when arriving. IBCLC will provide hands-on help with the baby at the breast as needed and will address your breastfeeding challenges and questions. I understand I need to inform KO Lactation if anyone in my home, including myself, has any signs of illness prior to the consultation or if anyone in my home, including myself has recently been exposed to a person with known Covid-19 infection. The Kate Ogilvie Lactation Consulting, Inc. cannot be held accountable for the transmission of any disease or illness I give my consent for the LC to send any and all pertinent information to my infant’s and my primary health care providers, and to consult with them in any way she deems appropriate including electronic transmission of such information. I give my consent for the LC to release pertinent information to my insurance company as necessary. I give my consent for the LC to use clinical information obtained during these sessions for education of other health care providers or mothers about lactation. Information used in this way will not contain my name or my baby’s name but aspects of my situation might be described or discussed. I understand that total payment is expected at the conclusion of the consultation unless prior arrangements have been made. I further understand that I will receive appropriate forms that can be submitted to my insurance company for reimbursement. I understand that Kate Ogilvie Lactation Consulting Inc. will protect the privacy of my personal health information as required by the Code of Professional Conduct of the International Board of Lactation Consultant Examiners (IBLCE), the International Lactation Consultant Association (ILCA) Standards of Practice and in compliance with the Federal Health Insurance Portability and Accountability Act of 1996(HIPAA). I give my consent to receive emails or phone calls from Kate Ogilvie Lactation Consulting Inc. from time to time regarding information, a product, service or survey that may interest me. I acknowledge that I have had full opportunity to discuss and understand information and treatment options provided by the Lactation Consultant. I understand that I have the right to refuse any or all specific techniques or treatments suggested, and any or all equipment provided or recommended to assist or remedy breastfeeding problems. I agree to the terms of Consent for Care and Treatment as outlined above 1 + 8 = Submit
