HomePatient Forms & PoliciesHome Visit Safety Acknowledgment
Service-specific consent
Home Visit Safety Acknowledgment
Safety expectations and conditions that apply when a Bayou City Breastfeeding clinician visits your home.
The full Home Visit Safety Acknowledgment is provided as a PDF.
Use the Download PDF button above to read the complete document. You’ll review and sign this form through Jane, our practice-management system, when you schedule a visit that includes a home visit.
If you’d like a copy of an earlier version, or if you have a question about anything in this document, email admin@bayoucitybreastfeeding.com. We won’t begin treatment until you’ve had the opportunity to review the documents and ask questions.
What this document covers
The Home Visit Safety Acknowledgment describes the basic safety expectations that apply when a Bayou City Breastfeeding clinician visits you at home: that the clinician will have a safe, accessible place to work; that anyone with an active contagious illness should not be in the immediate area of the visit; that firearms must be safely stored; that pets must be secured if they are reactive to strangers; and that the clinician may end the visit if safety conditions are not met.
How it fits with the other forms
This consent is reviewed in addition to the four intake documents when you schedule the corresponding service. You only see and sign it when that service is on your appointment.
Questions before you sign?
Email admin@bayoucitybreastfeeding.com or call (281) 305-0411. We’re happy to walk through any section with you before your first visit.
Ready to schedule?
When you book a visit, Jane sends you the intake documents and the consent for the service you’re scheduling. Request Appointment or call (281) 305-0411.