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

seven years.


Fee Policy: 

Blue Cross Blue Shield and Cigna customers please click here for find out if your fees will be filed for you.

All other insurance customers agree to the fee policy below: 

Fees for In-Office Consultations (for patients of Carolina Pediatrics of the Triad):


$95 for 60 minutes.


Fees for Virtual and Telephone Consults:

$30 for 15 minutes

$45 for 30 minutes

$60 for 45 minutes

$75 for 60 minutes. 

A Square invoice will be emailed to you for telephone or virtual consults.  


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


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.



Mother's Signature *
Powered byFormsite
Secured by Formsite