Client Consent Form

Business Name: Nurtured With Joy

Lactation Consultant (IBCLC): Chelsea Thomas-Hamblin

1. Maternal Assessment & Breast Examination

I consent to a maternal lactation assessment, which may include discussion of feeding history, observation of feeding, and visual and/or hands-on examination of my breasts and nipples only where clinically indicated and with my permission at the time.

I understand that:

• Any breast or chest examination will be explained beforehand

• My consent will be checked again verbally before any hands-on assessment

• I may decline or stop the examination at any time

2. Lactation & Feeding Assessment

I consent to a lactation and feeding assessment, which may include:

• Observation of my baby feeding at the breast and/or bottle

• Assessment of positioning, latch, milk transfer, and feeding behaviours

• Discussion of milk supply, feeding plans, expressing, and supplementation if relevant

3. Medical & Health History

I consent to providing a relevant maternal and infant medical history, including pregnancy, birth, medications, and health conditions, for the purpose of safe and appropriate lactation support.

I understand this information is used to:

• Individualise feeding advice

• Identify factors that may affect feeding or milk supply

• Support safe clinical decision-making

4. Infant Assessment & Oral Examination

I consent to a general infant feeding assessment, which may include observation of my baby’s behaviour, posture, and feeding cues.

I consent to an infant oral examination, which may include visual and gentle hands-on assessment of my baby’s mouth (lips, tongue, palate, jaw, and oral function) for feeding purposes only.

I understand that:

• This assessment is not a medical or diagnostic examination

• No procedures will be performed

• Any concerns identified may be discussed and, where appropriate, referral suggested

5. Record Keeping & Notes

I consent to the recording and storage of consultation notes, which may include:

• Electronic records stored securely via Squarespace and associated third-party systems

• Handwritten notes stored securely

I understand that:

• Records are kept confidential in accordance with data protection legislation

• Information is used solely for continuity of care, clinical documentation, and legal record-keeping

• Records will not be shared without my consent unless required by law or safeguarding concerns

6. Scope of Practice & Emergency Care

I understand that the lactation consultant:

• Works within their professional scope of practice

• Provides evidence-based lactation and infant feeding support

• Does not diagnose medical conditions or replace medical care

I understand that:

• Lactation support is not emergency medical care

• If I or my baby require urgent medical attention, I should contact emergency services, my GP, midwife, health visitor, or attend A&E as appropriate

Please complete the form below and contact me directly if you have any questions