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 agree to receive (I "opt in" to receiving) SMS text messages from GLC. Message and data rates may apply, and message frequency varies. 

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.

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 rendered.

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

The out of pocket fee for service is $95 for one hour

Fees for Virtual and Telephone Consults:

$45 for 30 minutes; $75 for 60 minutes. 

No Show and Cancel Fee

$35  failure to show for my appointment, or canceling my appointment without providing a 24 hour notice.

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

I understand that Greensboro Lactation Consultants accepts fee for service at the time of service, and a receipt for reimbursement will be provided upon request. 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 *
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