Mothering with Heart

Lactation Counseling Agreement

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​I grant permission for breastfeeding counseling services with Alicia Burgett, owner of Mothering with Heart. I understand that this service may consist of a medical history of me and my baby, a physical assessment of my breasts, an assessment of how my baby breastfeeds, including an examination/assessment of his/her mouth and tongue, the use of breastfeeding aids and equipment, helpful hints, and other educational information to help me breastfeed.

I authorize Mothering with Heart to release the information gained during the session to my primary care physician or other health care provider.

I understand that all medical care for me and my baby is to be provided by my physician(s)/health care providers and my baby’s physician.

I understand that payment is due by/at the time services are rendered, and I accept payment responsibility regardless of insurance or other third-party involvement.

I voluntarily release, waive, and discharge Mothering with Heart and its owner from any claims, liabilities, demands, actions, or causes of action arising out of or related to any loss, damage, or injury that may be sustained by myself, whether caused by Mothering with Heart or otherwise, to the fullest extent permitted by law.

I agree to indemnify, defend, and hold harmless Mothering with Heart from any and all costs, claims, or damages arising from my actions or participation in the services, activities, or events.

This Waiver shall be governed by and construed in accordance with the laws of the State of Washington.

This Waiver contains the entire agreement between the parties and supersedes all prior agreements or understandings, whether written or oral.