Master Intake Acknowledgment

By signing below, I have reviewed and agree to each of the following Bayou City Breastfeeding documents at the version shown. The General Consent contains the consumer disclosures required for electronic records and signatures. The Notice of Privacy Practices contains the Texas Health & Safety Code §181.154 notice on electronic disclosure of protected health information. I may request a paper or emailed copy of any document at any time at no charge.

• General Consent v2026.1 — bayoucitybreastfeeding.com/consents/general-consent-2026-1

• Notice of Privacy Practices v2026.1 — bayoucitybreastfeeding.com/consents/notice-of-privacy-practices-2026-1

• Good Faith Estimate / Surprise Billing Notice v2026.1 — bayoucitybreastfeeding.com/consents/good-faith-estimate-2026-1

• Payment-Related Consent v2026.1 — bayoucitybreastfeeding.com/consents/payment-related-consent-2026-1

I understand that visit-specific consents (lactation, chiropractic, therapeutic laser, home visit) and the optional HIPAA Marketing Authorization will be presented separately when they apply to me.