Consent to Care

I give my permission to Suckle and Spritz Lactation to treat me and my baby for feeding and lactation problems. This includes but may not be limited to: observing breastfeeding sessions, evaluating latch and positioning, providing hands-on assistance or evaluation of the breasts if necessary, evaluation of baby’s mouth, weighing baby, demonstrating techniques and recommending feeding plans. This extends to all in-person or virtual video appointments, as well as any external communication via phone or text.

I acknowledge Suckle and Spritz Lactation consultant will provide a suggested treatment plan to the best of their skill and knowledge, developed collaboratively with me to meet my feeding goals.

I acknowledge that written and verbal education will be provided and implementation of this education or plans are my (the parent) responsibility. I acknowledge that I will be provided with recommendations for follow-up based on the treatment plan, and that scheduling appropriate follow-up may impact the results of treatment plan.

I acknowledge results may vary based on variations in anatomy, individual health factors and adherence to treatment plans.

I will be in timely communication with the Suckle and Spritz Lactation consultant if issues should arise that I would like to be treated and addressed by them.

If I would like the IBCLC to communicate with my pediatrician or other provider, additional consent will be provided.

The information I provide is correct and true to the best of my knowledge.

Financial Responsibility (For those covered by The Lactation Network ONLY):

I understand that if approved by The Lactation Network, services rendered by Suckle and Spritz will be covered by them, as stated in any communications between myself, TLN, and Suckle and Spritz. If notified that visit coverage is limited by TLN I will notify Suckle and Spritz of the change in status.

I understand that any Explanation of Benefits generated from TLN appointments are NOT A BILL and TLN Explanations of Benefits are not reflective of the rates charged by Suckle and Spritz lactation, nor indicate the amount of patient responsibility (which is $0).

Financial Responsibility (For Self-Pay ONLY):

I understand that if using self-pay, Suckle and Spritz Lactation payments are due at the time of booking and a super-bill will be provided within 72 hours of services rendered (unless agreed upon otherwise)for the purpose of submission to insurance.

I agree to pay $200 for an in-home and $150 for virtual visits.

Travel Fee:

$50 travel fee may apply if drive time exceeds 30min, however, this only applies if notified at booking.

Cancellation Fee:

$50 cancellation fees may apply if cancellation is habitual, as last minute appointments are hard to fill. I will provide the IBCLC notification of cancellation 24 hours in advance whenever possible.