Consent Form

For Lactation Consultation

👉 Parental Consent for Lactation Support Services

This form seeks your consent for lactation support sessions, including video calls (if applicable). Your privacy and comfort are our priority. Please read each section carefully and provide your consent.

Parent Information

Parent’s Full Name (Required) Baby’s Full Name (Required) Baby’s Date of Birth (Required) Contact Number (Required) Email Address (Optional)

Consent for Lactation Support

I consent to participate in lactation support sessions. I understand that this consultation may include advice on breastfeeding, latching, positioning, pumping, and milk storage. I acknowledge that this service complements pediatric care and does not replace medical advice if my baby is unwell.

Consent for Video Call Sessions

I understand that during online/video consultations, I may be asked to show my breast or baby’s latch for proper assessment. I consent to show my breast during video calls only for clinical purposes. I understand that my privacy and dignity will always be respected during such sessions.

Confidentiality & Privacy

I confirm that photos, videos, or recordings will never be taken, stored, or shared without my explicit written permission. I understand that my consultations are strictly confidential and information will not be disclosed to third parties, except when required by law.

Teleconsultation Disclaimer

I understand the limitations of teleconsultation (video/phone) compared to in-person visits. I agree to seek immediate in-person medical care if my baby or I require urgent attention.

Acknowledgement & Consent

Parent/Guardian Full Name (Type as Signature) Date (Auto-captured)

Dr. Sakti Priya Pediatrician

Dr Sakti Priya
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