Consent for Virtual Breastfeeding Consult

Please answer all questions and hit submit before our scheduled virtual consult. Thank you!

Date (required)

Your Name (required)

Baby's Name (required)

Your Email (required)

Reason for our consult?

What is your current breastfeeding goal?

Consent for Virtual Session:

By typing my Full Name and submitting this form, I am requesting a virtual breastfeeding consultation with Melissa Schiff, IBCLC for myself and my infant/s. The consultation may include but not be limited to:
• a visual examination of my breasts
• a visual examination of my baby's mouth
• an observation of a breastfeeding session
I understand that Melissa will do her best to answer all my questions, but some breastfeeding situations are more in-depth requiring an In-person Breastfeeding Consultation. If Melissa feels my situation would be better handled with an In-person Breastfeeding Consultation she will recommend one for me. If I'm not in Melissa's area she will help me find a Lactation Consultant near me.

While the advice given by a Lactation Consultant is effective in most instances, I understand that these recommendations may not completely remedy or prevent adverse symptoms. The success depends, in large part, on my follow-through with the recommendations. I understand that my physician is my primary health care provider and that he/she is responsible for the overall care of my infant/s. All payments are due at the time of service.

Accept the terms

Please Type your full name (required):



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