1. I consent to a report of this lactation consultation being sent to my physicians, and additional persons as designated here: 2. I give my consent for information and any photographs from this consultation to be used, for educational purposes, and to promote breastfeeding, no names will be used.(Required) Yes, I give consent No, I do not give consent. 3. I agree to release information needed by my insurance company to process a claim for reimbursement.(Required) Yes, I give consent 4. I understand that this consultation will include physical examination of the mother's breasts, the baby's suck, and the observation of a breastfeeding session. It may include use of equipment to maintain lactation.(Required) Yes, I give consent Consultation rates are $200 for 90 minute First visit. Additional Visits are as stated on the website. Additional follow-up text messages (up to 3) will be at no charge. Additional consultation rates over the first hour will be billed at $25.00 per 15 minutes. Travel fee will apply at $45.00 (up to 20 miles). Supplies such as nipple shields, etc. will be an additional fee. <strong>FEES ARE DUE AT THE TIME OF THE APPOINTMENT.</strong>(Required) Yes, I understand your rates & policies. Name(Required) First Last Email (all reports and receipts will be emailed)(Required) Signature(Required) Reset signature Signature locked. Reset to sign again Date(Required) MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.