Legal Information

I am over the age of 18. If I am under the age of 18 but older than 13, I represent and warrant that my parent or legal guardian authorized to consent on my behalf has read the terms of this Informed Consent to Virtual Care Services (this “Consent”) and accepted them on my behalf.

I grant my permission for Care Services to be performed by employed and contracted certified lactation consultants and lactation allies of Milk Bar Collective, Inc. d/b/a MilkWise (collectively, my “Professionals” and each, my “Professional”). 

A lactation consultation, whether in person or virtual, usually includes visual and physical assessment of: 

• the breast/chest-feeding parent’s breasts
• visual and physical assessment of the infant’s mouth
• observation of the breast/chest-feeding parent and infant nursing
• analysis of the data relating to the breast/chest-feeding situation
• demonstration of techniques for improving breast/chest-feeding
• the use and demonstration of breast/chest-feeding equipment

I understand that all medical care is to be provided only by a physician(s). I give Milk Bar Collective, Inc. d/b/a MilkWise permission for information about this and all additional consultations to be sent to my attending/primary physician(s)/health care provider(s).

I understand the Professional will make recommendations toward helping me reach my breast/chest-feeding goals. I understand no outcome can be guaranteed. It is my responsibility to evaluate the effectiveness and sustainability of this care plan, and to contact my Professional for advice, adjustments, and follow up as necessary. 

I understand that I have the right to refuse any or all specific techniques suggested, equipment to assist or remedy breast/chest-feeding problems, and/or all recommended actions. 

I acknowledge that Milk Bar Collective, Inc. d/b/a MilkWise has provided their HIPAA policy and a HIPAA-compliant means of communication. 

If I choose not to use the HIPAA-compliant form of communication that Milk Bar Collective, Inc. d/b/a MilkWise has provided, I understand that, although email and text are not inherently secure means of communication, the Professional will take all reasonable precautions to protect my privacy. 

I understand that it is my choice to have someone else present during the visit and that anyone who sits in on the visit will have access to my healthcare care information and my confidentiality may not be guaranteed. I acknowledge that the Professional is not responsible for any breach of confidentiality made by anyone I invite to be present during a visit, or anyone added by me as a third party to text or email. 

I give my permission for information from this consultation/visit to be used to further the knowledge of breast/chest-feeding and/or educational purposes. 

I understand that my identity and the identity of my child(ren) will be kept private. 

I understand that no specific names will be publicly used. 

I understand that this consultation is not being recorded, and that no pictures or videos will be taken or shared from this consultation without me providing prior written consent.

I have read and reviewed Milk Bar Collective, Inc. d/b/a MilkWise payment policies and acknowledge that I am responsible for all charges associated with this visit. 

I give my permission for Milk Bar Collective, Inc. d/b/a MilkWise to bill my insurance and collect payment if I have not paid cash at the time of service. 

I give my permission for information to be released to my insurance company to assist in the evaluation of a claim. 

If I have not met my deductible, or my insurance does not pay, I agree to pay Milk Bar Collective, Inc. d/b/a MilkWise the balance of the consult. I have been given the cash rates for consultation. 

I agree with the use of digital signatures in my interactions with Milk Bar Collective, Inc. d/b/a MilkWise. Any signature of mine that is provided digitally will be assumed to carry all the weight and authority of an original manual signature.