Please fill out this information prior to your consultation so we can get to know you & your family!
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Please let us know how you heard about us so we can continue to reach other families the same way!
We fill up FAST! Payment is due immediately to guarantee booking confirmation. Please allow 24 for cancellations. No refunds. Thank you for your understanding!

GoldiLacts Release of Liability

I am agreeing to participate in a lactation and/or postpartum support consultation with GoldiLacts Lactation Consulting. GoldiLacts Lactation Consulting is a team of two certified lactation support specialists. Candice James holds the title of IBCLC. Candice Nicole Echeverria holds the title of Certified Breastfeeding Specialist and postpartum doula. Both Candice James and Candice Nicole Echeverria are certified to perform the tasks and duties which may or may not take place during this support session as outlined in both scopes of practice.

Covid-19 Clarifications and Declaration for IN-HOME services: Due to the 2020 Covid-19 pandemic faced by the U.S. which has been accompanied by strict shelter-in-place orders by local counties, GoldiLacts is taking extra precaution to ensure the health and safety of our support specialists as well as the safety of each family with whom they come into contact. We will be practicing in-depth sanitization practices including frequent hand washing, mask-wearing when handling baby, social distancing when not having physical contact with mother and/or baby, and sanitization of each product and piece of equipment used throughout the support session. 

Sessions will be rescheduled if your GoldiLacts support specialist is experiencing a temperature of 100.3 degrees or higher or any other symptoms of illness. Parents are to also inform GoldiLacts if they or anyone else in the home is experiencing a temperature of 100.3 degrees or higher and if so, the session will be rescheduled. If paid services cannot be fulfilled within two weeks due to GoldiLacts' inability to provide services in good faith, you will be provided a full refund. By signing this release, you declare that we have been invited to provide these services in person, in addition to your understanding that should anyone in your family be effected directly by Covid-19 following the administration of our services GoldiLacts will not be held liable physically or financially. No refunds for services will be provided due to the possible onset of Covid-19 following the administration of our services. 

This consultation may include visual and physical assessment of my breasts, observation of my baby nursing, visual and physical inspection of my baby’s mouth using gloved fingers for the purpose of examining suck patterns, and demonstrations of breastfeeding technique. I hereby permit the lactation specialist to assist me with any or all of the above. I understand that a more in-depth consultation with my physician or a referred provider may be needed and that all of my concerns may or may not have been solved upon completion of this consultation or any future consultations provided any member of the GoldiLacts team.

The services provided by the GoldiLacts certified lactation specialist are not a guarantee of specific results. These services are in no way intended as medical advice or to serve as a substitute for medical counseling. The recommendations provided should be used in conjunction with the guidance and care of your physician. The scope of these consultation services does not include prescription of medication, treatment for, or diagnosis of specific illnesses or diseases for myself or my infant/s. In the case that a specific health issue beyond our scope of practice is suspected, a referral to another provider may be suggested.

I understand that a certified lactation specialist is not a registered nurse, pediatrician, physician, or other licensed medical professional and they practice within a limited scope of lactation services. Should I desire to obtain a copy of the scope of practice one can be provided upon request.

This consent is binding for this and any future consultation services given by a member of the GoldiLacts team. Consultations may be given in person as well as via phone, text, or email. I understand that I am responsible for informing my lactation specialist of changes that are necessary to the care plan during this visit or during the course of follow-up communications.

Payment for this visit is due immediately. Payments can be made via the Venmo or PayPal smartphone app, or cash on site at the time of service. If requested, clients will receive a paid invoice as part of a set of follow up documents to be used as a resource upon completion of their initial consultation. This payment is for a voluntary, in-home OR virtual (online) lactation and/or postpartum consultation service and I understand that this payment is non-refundable. Please communicate with your lactation specialist prior to your session to indicate your method of payment. 

Venmo for Candice James: @candicejgoldilacts

Venmo for Candice Nicole: @goldilactscan

PayPal can be accessed using the direct phone number or email of your lactation specialist which has been provided to you via text message prior to filling out your intake forms. Please select "Friends & Family" when submitting payment to avoid any additional fees or deductions.

I understand that GoldiLacts (TaxID# 82-1977838) is not affiliated with any insurance companies, nor does GoldiLacts bill insurance companies for reimbursement. I understand that it is my choice to submit the paid invoice provided to me by GoldiLacts Lactation Consultation is merely a proof of services rendered and that my insurance company has its own policies and standards for reimbursement.

It has been explained that further text/phone support is available to me upon the completion of my initial consultation with GoldiLacts. I understand said phone support to be limited and that my lactation specialist will make me aware of when an additional paid in-person (or paid phone) consultation is necessary per their discretion. I have the right as the client to choose whether or not the scheduling of this paid follow up consultation or instead forfeiting further phone/text support with my lactation specialist moving forward.

 

By typing my name below and submitting this form, I acknowledge that this consent serves to release GoldiLacts Lactation Consulting and all associated members of the GoldiLacts lactation/postpartum support team from liability for any and all loss, injury, or damages.

Photo & Video Consent
We frequently use our mobile device or camera to take footage of the client(s) in order to provide media resources of the areas we are troubleshooting. Please select an option here to indicate your permission for GoldiLacts to use this footage for the purposes of future tutorials and workshops. We appreciate your participation as this helps other families who may be facing the same challenges! Your names and other information will remain confidential.