Lactation Consultant (IBCLC) Consent to Assess & Treat

# Lactation Consultant (IBCLC) Consent to Assess & Treat **Practice / Consultant:** ___________ **IBCLC Name:** ___________, IBCLC, certification number ___________ **Date of Consent:** ___________ --- ## Patient / Client Information **Patient (parent/guardian) name:** ___________ **Date of birth:** ___________ **Infant name:** ___________ **Infant date of birth:** ___________ **Infant gestational age at birth:** ___________ weeks **Primary care provider (parent):** ___________ **Infant's pediatrician/family physician:** ___________ **Phone:** ___________ **Email:** ___________ --- ## 1. Purpose and Scope of Lactation Services An International Board Certified Lactation Consultant (IBCLC) is a health professional certified in the clinical management of lactation and breastfeeding. The IBCLC will assess breastfeeding/chestfeeding, provide education and support, and make evidence-based recommendations to promote optimal infant feeding. Services provided may include: - Oral assessment of the infant (latch, suck, tongue function) and oral anatomy screening (e.g., screening for ankyloglossia/tongue-tie) - Evaluation of milk supply, transfer, and infant weight trends - Instruction on positioning, attachment, pumping, and milk storage - Development of an individualized feeding plan