Greensboro Lactation Consultants, LLC
Consent for Breastfeeding Consultation Services
I grant my permission for breastfeeding consultation services to be performed by
Greensboro Lactation Consultants, LLC (GLC). GLC is not an affiliate, employee, or agent of another health care provider, including Carolina Pediatrics of the Triad.
I understand that this consultation may consist of the following:
A medical history of my baby and me,
A physical assessment of my breasts,
An assessment of how my baby breastfeeds including an examination of his/her mouth
and tongue, the use of breastfeeding aids and equipment, helpful hints and other
educational information to help me breastfeed.
I authorize the breastfeeding consultant to release the information gained from
the consultation to my primary care physician(s), health care provider, and
insurance company (to assist with claim reimbursement).
I understand that all medical care for my baby and me is to be provided by our
physician(s) and health care providers. I understand that all health care issues of a
medical nature must be discussed with a physician.
I understand that the HIPAA Privacy Practices have been made available to me and are
available for me to read on the website
I understand and agree that the information in this file will be kept for a period of
I accept payment responsibility for the breastfeeding consultation, and equipment
rental or purchase, regardless of insurance or other third party involvement. I
authorize the undersigned consultant to charge my credit card for services
Fees for In-Office Consultations (for patients of Carolina Pediatrics of the Triad):
The fee for service is as follows: $15 for 15 minutes; $35 for 30 minutes; $55 for 45 minutes; $75 for 60 minutes.
Fees for In-Home Consultations:
The fee for service is as follows: $35 for 15 minutes; $55 for 30 minutes; $75 for 45
minutes; $95 for 60 minutes. Prices will be combined for consultations over one hour.
Travel fees are in addition to the consult fee:
$10 for Jamestown, Pleasant Garden.
$20 for Oak Ridge, Summerfield, Browns Summit, High Point, Climax, Whitsett, Kernersville, Randleman.
$30 for Burlington, Winston Salem, Stokesdale
I understand that Greensboro Lactation Consultants accepts fee for service at the time
of service, and a receipt for reimbursement will be provided. It is my responsibility to
pursue reimbursement for lactation services from my insurance company. Greensboro
Lactation Consultants is not responsible for, nor does it guarantee reimbursement.