Home Visit Safety Acknowledgment

This acknowledgment applies when Bayou City Breastfeeding provides services in my home or another private location I request.

Purpose

Bayou City Breastfeeding provides home visits only when the environment is reasonably safe for the client, baby, provider, and any staff or trainees present. I understand that the provider may delay, end, reschedule, or decline a home visit if the provider determines that the environment is unsafe, inappropriate for care, or not suitable for the scheduled service.

Adult presence

A responsible adult must be present for the visit. If the visit involves a minor, a parent, guardian, managing conservator, or other legally authorized adult must remain present for the entire visit.

Pets and animals

I agree to secure all pets before the provider arrives and keep them secured during the visit unless the provider gives permission. If a pet or animal creates a safety concern, the provider may pause, end, or reschedule the visit.

Weapons and safety hazards

I agree that any firearms or other weapons in the home will be unloaded and stored out of the room where care is delivered for the duration of the visit. The provider may leave or reschedule if a firearm is visible in the care area or if the provider observes any unsecured weapon.

Smoke, substances, and air quality

I agree to provide a visit environment that is reasonably free of smoke, vaping, strong odors, or substances that could interfere with safe care. The provider may leave or reschedule if the environment creates a health or safety concern.

Illness and infection precautions

I agree to notify Bayou City Breastfeeding before the visit if anyone in the home has symptoms of contagious illness, including fever, vomiting, diarrhea, new rash, flu-like symptoms, COVID-19 symptoms, or another contagious condition. Bayou City Breastfeeding may reschedule, convert to virtual care when appropriate, or require precautions.

Parking and access

I agree to provide accurate address, parking, gate, building, and access information before the appointment. If the provider cannot safely access the location, cannot park safely, cannot enter the building, or cannot reach me, the appointment may be treated as a late cancellation or no-show under the Payment-Related Consent.

Home environment

I agree to provide a reasonably clean, safe, and accessible area for care. The provider may ask to move to a different area of the home if needed for safety, privacy, lighting, space, or care quality.

Provider right to leave

The provider may leave immediately if the provider feels unsafe or unable to provide care appropriately. Reasons may include aggressive or threatening behavior, unsecured animals, weapons or visible safety hazards, unsafe parking or access, harassment, intoxication or impairment by anyone present, illegal activity, unsafe physical conditions, lack of required adult presence, or refusal to follow reasonable safety requests.

Emergency care

Bayou City Breastfeeding does not provide emergency medical care. If I or my baby has a medical emergency, I should call 911 or go to the nearest emergency department. If a medical emergency occurs during a home visit, the provider may call 911 or instruct me to call 911.

Provider emergency or safety concern

If a provider emergency, travel emergency, or safety concern occurs during travel to or from my home, Bayou City Breastfeeding may share my appointment location with appropriate BCB personnel, emergency contacts, or emergency responders as needed.

Fees

Home visits may include travel fees as described in the Payment-Related Consent. If a visit cannot be completed because the location is unsafe, inaccessible, or unsuitable for care, cancellation, no-show, travel, or other fees may apply as described in the Payment-Related Consent.

Recording by client

I will not audio- or video-record the in-home visit without the provider's prior written consent.

Provider location-sharing and electronic disclosure

BCB may use GPS navigation and cellular communication during travel to and from my home. If a provider safety or travel emergency occurs, BCB may share my appointment location with appropriate BCB personnel, emergency contacts, or emergency responders. This is an electronic disclosure of limited PHI consistent with BCB's Notice of Privacy Practices and Texas Health & Safety Code §181.154.

Alternative Care after Cancelled Home Visit

If BCB delays, ends, or declines the home visit for safety, illness, or environmental reasons, BCB will, when reasonable, offer me a virtual visit or an in-office visit as an alternative. If a virtual or in-office alternative is offered and I decline, applicable cancellation, no-show, or travel fees may apply as described in the Payment-Related Consent.

Electronic Signature, Governing Law, and Scope

Electronic Signature. If I sign this consent electronically, my electronic signature has the same legal effect as a handwritten signature under the federal E-Sign Act (15 U.S.C. §7001) and the Texas Uniform Electronic Transactions Act. The General Consent contains the full E-Sign consumer disclosure block applicable to all Bayou City Breastfeeding forms I sign.

Governing Law. This Consent is governed by the laws of the State of Texas. Severability. If any provision of this consent is held invalid or unenforceable, the remaining provisions will remain in full force and effect.

Scope: This document addresses the matters set out above and does not limit or supersede any separate document I sign with Bayou City Breastfeeding, including the General Consent, the Treatment Consent for the service I am receiving, any Good Faith Estimate, or any other practice form or policy.