RECLAMATION LACTATION CONSENT FOR CARE
CONSENT FOR CARE FOR IN-PERSON LACTATION AND ORAL/MANUAL THERAPIES
(Updated: 04/27/2026)
I understand that during a consultation for lactation support and/or oral and bodywork therapies, Kaytee Crawford, IBCLC, CST, may perform assessments and provide care to both me and my baby or babies. This may include visual and manual examination of my breasts/chest (for lactation consultations), assessment of my oral function if relevant, and visual and manual assessment of my baby or babies, including an oral exam using a gloved finger. Care may also include observation of feeding, clinical assessment, education, demonstration of techniques, guidance on bodyfeeding equipment, and individualized recommendations to support our feeding goals. I understand that no specific outcome can be guaranteed.
I understand that these services are supportive, educational, and collaborative in nature. They are not a substitute for medical diagnosis or treatment. Kaytee Crawford does not diagnose medical conditions or prescribe treatment, and may recommend referral to other qualified healthcare providers when appropriate.
I agree to provide accurate and up-to-date information, including the names and contact information of relevant healthcare providers for myself and my baby or babies. I give permission for Kaytee Crawford to communicate with these providers as needed for continuity of care.
I understand that email and text messaging are not secure forms of communication and may include Personal Health Information (PHI). I consent to communication via email and text. I understand that if I include a third party in any email or text communication, I am granting permission for Kaytee Crawford to share relevant health information with that individual. Kaytee Crawford will not independently add third parties to communication without my consent.
Because services may take place in my home, I understand that Kaytee Crawford may use GPS for navigation and her emergency contact has access to her location at all times for her safety.
I understand that I may choose to have another person present during the visit. I acknowledge that any individual present may have access to my health information, and confidentiality cannot be guaranteed in those situations. I accept responsibility for any potential breach of confidentiality involving individuals I invite to be present or include in communication.
I confirm that I have reviewed and understand the payment policies and agree to be responsible for all charges associated with services provided, unless otherwise arranged through sliding scale or pro bono agreement. I understand that Kaytee Crawford provides care to both me and my baby or babies, and that all are considered clients within the scope of care. I authorize communication with my insurance provider as needed for billing or reimbursement purposes.
I understand that Kaytee Crawford may communicate with my financial institution for payment processing. I agree to provide accurate and current payment and insurance information.
I give permission for Kaytee Crawford to use HIPAA-compliant AI-assisted documentation tools to support accurate and thorough clinical record-keeping due to Kaytee Crawford’s diagnosed neurodivergence.