I have specifically requested this consultation and have agreed that it will include face-to-face observation of a full breastfeed in my home or visible via Skype Video.

Agree to provide a client history/record to the consultant in preparation for a planned breastfeeding consultation.

Give my permission (under rare circumstances) in a face-to-face consultation, for the consultant to assist with a breastfeed(s) that may involve ‘hands-on’ my breast(s) or my baby for a specific reason, and this would only be with my consent.

Agree to the consultant checking my breastfeeding technique, observing my baby’s application to breastfeed or, in some circumstances possibly examining my baby's intra-oral function and sucking rhythm.

Understand that sometimes it may include the use of, or advice about, equipment or apparatus suitable for supporting breastfeeding and/or milk production.

Understand that each consultation incurs a fee-for-service that will be paid at the time of making the appointment.

Give my permission for de-identified data/information from this breastfeeding consultation to be used for the purpose of furthering education and knowledge, and knowing that the de-identified information may be used for breastfeeding research according to the Privacy Act.

Give my permission for photographs/video clips to be taken of me and/or my baby to be used for educational purposes and to promote breastfeeding providing no specific names are used. I realise that in giving this permission some photographs or video clips may identify me and/or my baby(s).

I have read the Consent to a Breastfeeding Consultation, I am aware of my Privacy rights and acknowledge when I press submit I have accepted these points for my Consultation.