Consent Form

Alicia Cole IBCLC Infant Feeding & Independent Health Visiting Services
Website: aliciacole.co.uk

Please read this information carefully. By ticking the consent box on the booking form, you confirm that you understand and agree to the following terms:

1. Consent for Services

I consent for Alicia Cole to work with me and my baby during this consultation to support infant feeding and/or child health concerns. This includes consent for her to:

Visit me in my home (for in-person consultations),
Contact me by telephone, WhatsApp and email regarding the appointment and for appropriate follow-up communications.

2. Nature of the Consultation

I understand that an infant feeding or child health consultation may include:

Touching my breasts and/or nipples (with permission) for assessment,
Inserting gloved fingers into my baby's mouth to assess suck,
Observation of feeding and suggestions regarding positioning or latch,
Demonstration of techniques or equipment.

I understand that participation is voluntary and I may decline or withdraw consent to any aspect of the consultation at any time.

3. Responsibility & Boundaries

I understand that:

It is my responsibility to update Alicia Cole with progress, concerns, or questions following the consultation.
This is a professional relationship governed by professional boundaries, including communication and use of social media.
Alicia Cole is bound by the Nursing and Midwifery Council (NMC) Code and ethical standards set by the International Board of Lactation Consultant Examiners (IBLCE).

4. Information Sharing

I give consent for Alicia Cole to share relevant information from the consultation with other healthcare professionals involved in mine or my child’s care, such as our GP or NHS Health Visitor, where appropriate and after prior discussion with me.

I understand that in safeguarding situations (where a child may be at risk), Alicia Cole may need to contact children’s services without my prior agreement if she believes this is in the child’s best interest.

5. Use of Clinical Information

I consent to the use of anonymised clinical information from our sessions for educational purposes (e.g., training other professionals or informing other parents). Neither I nor my child will be identifiable.
If I object to my case being discussed in this way, I will inform Alicia Cole directly.

6. Payment

I understand that full payment is due at the end of the consultation unless otherwise agreed in advance.

7. Confidentiality & Data Protection

I understand that:

Alicia Cole is committed to protecting my personal health information in line with the NMC Code, ILCA Standards of Practice, and GDPR (2018).
Information collected includes: my name, age, address, contact details, child’s name and date of birth, medical history, consultation notes, weight charts, care plans, and reports (e.g. to GPs).
This data is collected only when necessary for safe and effective care delivery.
My data will be securely stored for 25 years in accordance with legal requirements.

My information will never be used for marketing purposes. I may be contacted about relevant services in the future unless I opt out.

8. Your Data Rights

Under GDPR, I have the right to:

Access my data,
Request correction of inaccurate data,
Request deletion of data (where lawful),
Lodge a complaint if I believe my data has been misused.

9. Communication & Accessibility

I understand that all communication is in English. If I need assistance with reading, writing, or comprehension, or require a translator, I will notify Alicia Cole in advance. Translation services can be arranged at an additional cost.

10. Raising Concerns

If I have any questions, concerns, or complaints about the care I receive or any of the above terms, I agree to contact Alicia Cole directly. Raising concerns or setting boundaries will not affect the quality or professionalism of care I receive.

By ticking the box on the booking form, I confirm that I have read, understood, and agree to the above terms.