Consent for Care for Telelactation

I understand that during a virtual consult for lactation support, Dalal AlZabin IBCLC may examine me and my breasts visually, may examine me and my baby or babies visually, may observe me and my baby while feeding, may make clinical observations, may provide information on techniques and breastfeeding, pumping, and feeding equipment, and will make recommendations towards helping me reach my goals. Dalal AlZabin will guide me in positioning my camera to be able to see me and my baby, and will direct me in assessments of my breasts and/or my baby in the furtherance of my care.

I understand no outcome can be guaranteed. I acknowledge that there may be some limitations with virtual care.

I will provide Dalal AlZabin with the names and contact information for other relevant healthcare providers for me and my baby, and Dalal AlZabin may communicate with them. It is my responsibility to provide accurate information and to keep it updated. 

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 information and my confidentiality may not be guaranteed. I have provided written notice to Dalal AlZabin of any person(s) I wish to have present during the visit. I understand that if I include any third party on an email or text with Dalal AlZabin, I am granting permission for Dalal AlZabin to communicate my health information and that of my baby or babies with that third party. Dalal AlZabin will not initiate inclusion of any third party on an email or text. I acknowledge that Dalal AlZabin is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party to text or email. 

I have read and reviewed Dalal AlZabin’s payment policies and understand that I am responsible for all charges associated with this visit. Dalal AlZabin is providing care to me and to my baby or babies; together we are all the client of Dalal AlZabin. Dalal AlZabin may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment information. 

I give permission to Dalal AlZabin to photograph or record video of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my baby’s healthcare team. 

If you are unable to access secure video:

In order to provide care to you as quickly as possible, I am using a non-HIPAA compliant service called Zoom to provide video care for you and your baby. The Department of Health and Human Services is temporarily allowing this exception and I will be moving to a HIPAA-compliant platform as soon as I am able.

If your client cannot access your secure platform:

We may use the non-HIPAA compliant platform of your choice, as long as it is private.