Please locate the appropriate consent for care for Twin Mom Guide private lactation services and review. If you have any questions, please do not hesitate to contact Shelly Patularu.
Consent for Care for Telehealth (USA)
I understand that during a virtual consult for lactation support, Shelly Patularu, BScN, RN, IBCLC, may examine me and my breasts visually, may examine me and my baby or babies visually, may observe me and my baby/babies while feeding, may make clinical observations, may provide information on techniques and breastfeeding, pumping, and feeding equipment, and will make recommendations towards helping me reach my goals. Shelly Patularu will guide me in positioning my camera to be able to see me and my baby, and will direct me in assessments of my breasts and/or my baby/babies in the furtherance of my care.
I understand no outcome can be guaranteed. I acknowledge that there may be some limitations with virtual care.
I will provide Shelly Patularu with the names and contact information for other relevant healthcare providers for me and my babies, and Shelly Patularu may communicate with them. It is my responsibility to provide accurate information and to keep it updated.
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 Shelly Patularu 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 Shelly Patularu, I am granting permission for Shelly Patularu to communicate my health information and that of my baby or babies with that third party. Shelly Patularu will not initiate inclusion of any third party on an email or text. I acknowledge that Shelly Patularu 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 Shelly Patularu’s payment policies and understand that I am responsible for all charges associated with this visit. Shelly Patularu is providing care to me and to my baby or babies; together we are all the client of Shelly Patularu. Shelly Patularu may communicate with my insurance company in reference to the services provided to me and my baby or babies. Shelly Patularu 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.
Shelly Patularu provides a secure messaging portal through Practice Better. I understand that I am not obligated to use secure messaging, and if I opt out of secure messaging by initiating communication by text or email Shelly Patularu will respond. I understand that email and text are not secure means of communication, and give my permission for Shelly Patularu to send and receive texts and emails that may contain my Personal Health Information (PHI) if initiated by me.
I give permission to Shelly Patularu to photograph or record video of me and/or my baby/babies in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my babies’ healthcare team.
If your client cannot access your secure platform:
We may use the non-HIPAA compliant platform of your choice, as long as it is private.
Consent for Care for Telehealth (Canada)
As Telelactation services are provided remotely, there is also a very mild risk of personal safety only in that there is no service provider directly with you to assist if you need. However, this would be no riskier than being at home alone. If you have significant mobility issues and/or do not feel safe being alone for care, we recommend you have someone present with you during your treatment.
Despite efforts to ensure high encryption and secure technology, there is always a risk that the transmission could be breached and accessed by an unauthorized person. However, all services are provided using a secure platform compliant with all applicable privacy laws.
Further, with an inability to perform hands-on examination, assessment via Telelactation may not be the most suitable treatment option.
I understand that during a virtual consult for lactation support, Shelly Patularu, BScN, RN, IBCLC may examine me and my breasts visually, may examine me and my baby or babies visually, may observe me and my baby/babies while feeding, may make clinical observations, may provide information on techniques and breastfeeding, pumping, and feeding equipment, and will make recommendations towards helping me reach my goals. I understand no outcome can be guaranteed. Shelly Patularu will guide me in positioning my camera to be able to see me and my baby/babies, and will direct me in assessments of my breasts and/or my baby/babies in the furtherance of my care. I give my consent to undergo such examination and assessment and know that I can withdraw my consent at any time and that I am free to bring an additional person to any treatment sessions to act as my advocate.
This will be discussed with you further, prior to your examination and Shelly Patularu will discuss any questions you may have regarding the exam.
I will provide Shelly Patularu with the names and contact information for other relevant healthcare providers for me and my baby, and I authorize Shelly Patularu to share my information as deemed necessary. I also understand that my personal and medical information is confidential and will only be disclosed to third parties (including medical doctor and healthcare providers) with my permission. It is my responsibility to provide accurate information and to keep it updated.
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 Shelly Patularu 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 Shelly Patularu, I am granting permission for Shelly Patularu to communicate my health information and that of my baby or babies with that third party. Shelly Patularu will not initiate inclusion of any third party on an email or text. I acknowledge that Shelly Patularu 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.
Shelly Patularu provides a secure messaging portal through Practice Better. I understand that I am not obligated to use secure messaging, and if I opt out of secure messaging by initiating communication by text or email Shelly Patularu will respond. I understand that email and text are not secure means of communication, and give my permission for Shelly Patularu to send and receive texts and emails that may contain my Personal Health Information (PHI) if initiated by me.
I have read and reviewed Shelly Patularu’s payment policies and understand that I am responsible for all charges associated with this visit. Shelly Patularu is providing care to me and to my baby or babies; together we are all the client of Shelly Patularu. Shelly Patularu may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment information.
I give permission to Shelly Patularu to photograph or record 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.
Consent to Care In-Person Visit (USA)
I understand that during a consult for lactation support, Shelly Patularu, BScN, RN, 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/babies 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 Shelly Patularu with the names and contact information for other relevant healthcare providers for me and my baby/babies, and Shelly Patularu 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 Shelly Patularu to send and receive texts and emails that may contain my Personal Health Information (PHI).
For Home Visits: Because Shelly Patularu will be coming to my home, I grant permission for Shelly Patularu 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 Shelly Patularu 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 Shelly Patularu, I am granting permission for Shelly Patularu to communicate my health information and that of my baby or babies with that third party. Shelly Patularu will not initiate inclusion of any third party on an email or text. I acknowledge that Shelly Patularu 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 Shelly Patularu’s payment policies and understand that I am responsible for all charges associated with this visit. Shelly Patularu is providing care to me and to my baby or babies; together we are all the client of Shelly Patularu. Shelly Patularu may communicate with my insurance company in reference to the services provided to me and my baby or babies. Shelly Patularu 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.
Shelly Patularu provides a secure messaging portal through Practice Better. I understand that I am not obligated to use secure messaging, and if I opt out of secure messaging by initiating communication by text or email Shelly Patularu will respond. I understand that email and text are not secure means of communication, and give my permission for Shelly Patularu to send and receive texts and emails that may contain my Personal Health Information (PHI) if initiated by me.
I give permission to Shelly Patularu to photograph or record video of me and/or my baby/babies 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/babies’ healthcare team.
Consent for Care for In-Person Visits (Canada)
Shelly Patularu, IBCLC, is providing care to me and to my baby/babies; together we are all the client of Shelly Patularu, Twin Mom Guide.
I understand that during a consult for lactation support, Shelly Patularu, 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/babies 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 give my consent to undergo such examination and assessment and know that I can withdraw my consent at any time and that I am free to bring an additional person to any session to act as my advocate.
This will be discussed with you further, prior to your examination and Shelly Patularu will discuss any questions you may have regarding the exam.
Shelly Patularu will protect my personal information using secure accounts that comply with all applicable privacy laws. Shelly Patularu will provide me with policies and procedures related to the protection of personal information upon receipt of a written request.
I will provide Shelly Patularu with the names and contact information for other relevant healthcare providers for me and my baby, and I authorize Shelly Patularu to share my information as deemed necessary. I also understand that my personal and medical information is confidential and will only be disclosed to third parties (including medical doctor and healthcare providers) with my permission. It is my responsibility to provide accurate information and to keep it updated.
For home visits: Because Shelly Patularu will be coming to my home, Shelly Patularu 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 Shelly Patularu 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 Shelly Patularu, I am granting permission for Shelly Patularu to communicate my health information and that of my baby or babies with that third party. Shelly Patularu will not initiate inclusion of any third party on an email or text. I acknowledge that Shelly Patularu 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 Shelly Patularu’s payment policies and understand that I am responsible for all charges associated with this visit. Shelly Patularu may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment information.
Shelly Patularu provides a secure messaging portal through Practice Better. I understand that I am not obligated to use secure messaging, and if I opt out of secure messaging by initiating communication by text or email Shelly Patularu will respond. I understand that email and text are not secure means of communication, and give my permission for Shelly Patularu to send and receive texts and emails that may contain my Personal Health Information (PHI) if initiated by me.
I give permission to Shelly Patularu to photograph or record video of me and/or my baby/babies 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.
