Hello fellow friends,
I am attempting to make up a form for consent to formula feed. I feel that if a 
mom is informed of the risks and has to sign a consent, and the staff has to 
give a consent, less supplements will be given. I started using the regular 
consent forms available which were procedure/surgical consent forms but they 
are not as professional and seem a little tachy. What I have made up is this. 
I_________have given permission to feed my breast fed infant formula. I have 
been informed that feeding cow's milk formla will introduce my baby to cow's 
milk protein Allergic reaction to cow's milk could be eczema, vomiting, diarrhea 
and bloody stools. Alergic reaction to Soy formula could sensitize my infant to 
be allergic to peanuts, and other reactions could be eczema, vomiting and 
diarrhea and bloody stools. I have no previous history of cow's milk or soy 
allergy. My significant other has no history of cow's milk allergy or soy allergy.
Once tghese proteins are introduced, you cannot reverse the sensitivity. 
I also give permission for my baby to feed either by bottle, spoon, cup or 
finger feeding. I have been informed that if a bottle is introduced before 
breastfeeding has been established it may interfere with my baby's latch or he 
may not latch at all. Studies have shown that bottle feeding will cause babies 
to wean sooner. Once breastfeeding has been established one to two bottles 
per day will not interfere with breastfeeding.

Patient Signature __________
Date: _________
If you have something already in place, please feel free to email me privately 
or post.
Thanks,
Terri Klein RN CLE CLC

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