Consent for Care for In-Person Visits

I understand that during a consult for lactation support, Noelle Dimas IBCLC will examine me and my breasts both visually and manually, will examine me and my baby or babies both visually and manually (including an oral exam with a gloved finger), will observe me and my baby while feeding, will make clinical observations, will provide information on techniques and breastfeeding equipment, and will make recommendations towards helping me reach my breastfeeding goals. I understand no outcome can be guaranteed.

I will provide Noelle Dimas with the names and contact information of other relevant healthcare providers for me and my baby, and Noelle Dimas may communicate with them. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for Noelle Dimas to send and receive texts and emails that may contain my Personal Health Information (PHI). Because Noelle Dimas will be coming to my home, I grant permission for Noelle Dimas to give my address to Danny Dimas, and I understand that Noelle Dimas will use GPS to navigate to my home.

I understand that it is my choice to have someone else present during the visit and that anyone who sits in on the visit will have access to my healthcare information and my confidentiality may not be guaranteed. I have provided written notice to Noelle Dimas of any person(s) I wish to have present during the visit. I understand that if I include any third party on an email or text with Noelle Dimas, I am granting permission for Noelle Dimas to communicate my health information and that of my baby or babies with that third party. Noelle Dimas will not initiate inclusion of any third party in an email or text. I acknowledge that Noelle Dimas is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party to text or email. 

I have read and reviewed Noelle Dimas’s payment policies and understand that I am responsible for all charges associated with this visit. Noelle Dimas is providing care to me and to my baby or babies; together we are all clients of Noelle Dimas. Noelle Dimas may communicate with my insurance company in reference to the services provided to me and my baby or babies. Noelle Dimas may communicate with my credit card company or bank for any payment-related matters. It is my responsibility to provide accurate and current payment and insurance information. 

I give permission to Noelle Dimas to photograph or record a video of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my baby’s healthcare team.