Release of Information Form

I give my permission to Suckle and Spritz Lactation to share my protected health information and that of my baby with the providers listed below for the purpose of tracking progress, further evaluation, follow-up or if otherwise deemed necessary by parent or provider.

I acknowledge that other providers may require written consent to share information with Suckle and Spritz and I will complete any forms to release information to Suckle and Spritz if necessary.

(Fill out only the information for the providers you would like me to be able to share information with).

Breastfeeding Parent's Name

First Name

Last Name

Parent's Date of Birth

YYYY

Parent's Provider:

First Name

Last Name

Parent's Provider Phone Number

(###)

###

####

Parent's Provider Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Baby's Name

First Name

Last Name

Baby's Date of Birth

YYYY

Baby's Provider

First Name

Last Name

Baby's Provider Phone Number

(###)

###

####

Baby's Provider Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Other Specialist

First Name

Last Name

Specialty

Specialist's Phone Number

(###)

###

####

Specialist's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Adopt this as my electronic signature

Yes

Electronic Signature

First Name

Last Name

Date Signed

YYYY

Suckle & Spritz