Mothering with Heart
Alicia Burgett
Lactation Specialist & Holistic Sleep Coach
"Mothering is learned through connection, not perfection"
Lactation Counseling Agreement
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.
Communication Agreement​​​
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​Mothering with Heart partners with a Health Centered SMS Texting Application. This allows all communications to be
private.
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SPRUCE SMS Text Messaging Terms of Service
These SMS Text Messaging Terms of Service (these “SMS Terms”) are incorporated into all agreements between you and Mothering with Heart (“our organization”, “MWH”, “us”, “we”), including any agreements that are preexisting and any agreements that might be enacted contemporaneously with these SMS Terms.
Mothering with Heart might use SMS text messaging, from time to time, for certain types of communication with you, including potentially for administrative issues, such as billing, or for health-related issues, such as care reminders.
You agree to receive (you “opt in” to receiving) SMS text messages from Mothering with Heart, related to services that we are providing to you. Message and data rates may apply, and message frequency varies. You may text STOP at any time to opt out of receiving SMS text messages from MWH. You may text HELP at any time to receive help.
SMS text messages from Mothering with Heart may originate from our organizational phone number, (509) 267-6517.
There may be terms in other agreements between you and us that also apply to the organization’s use of SMS text messaging, such as general terms related to privacy and data handling for the organization that are not specific to SMS text messaging. You agree that you have reviewed all agreements that have been provided to you.
We respect your privacy and are committed to protecting your personal information. Any information collected as part of this SMS or text messaging program, including mobile phone numbers, messaging consent, and opt-in data, is used solely for the purpose of providing the messaging services you have opted-in to receive.
No mobile opt-in data or text messaging consent information will be shared, sold, rented, or disclosed to any third parties, except as required to deliver the messaging service or to comply with applicable laws.