RELEASE OF LIABILITY for the USE of NON-DONOR BANK BREAST MILK 

I UNDERSTAND and ACCEPT the following:

I have been advised that:

• Atkins Property Management LLC d/b/a Arkansas Lactation (hereafter “Arkansas Lactation”) does not guarantee that the breast milk donor has been screened for risk factors for blood borne pathogens that may be transmitted in breast milk. Arkansas Lactation does not guarantee that the donor milk has been pasteurized.
• The risk of administering unprocessed human breast milk includes transmission of infectious diseases including: hepatitis B and C as well as HIV and the human T cell leukemia virus and other unknown agents.

The risk of administering unprocessed human breast milk includes transmission of medications and other substances that can be potentially dangerous to the baby. A complete explanation was provided to me which I understood fully, and I have had my questions answered to my satisfaction. However, I view breast milk as an acceptable alternative to the birth mother’s own milk and preferable to formula. In spite of the risks outlined I, as my baby’s substitute decision maker and with the full approval of my spouse/partner, wish to feed my baby with breast milk provided by:

In consideration of being permitted to use non donor bank breast milk, I understand that the use of non donor bank breast milk may presents some unavoidable risk of injury, especially to people who may have pre-existing illness or medical disabilities, and I assume any and all risks associated with it.

I further agree and understand that Arkansas Lactation, including its employees, contractors, owners, agents, directors, successors, and assigns, will bear no liability for any and all injuries that may be sustained during participation in the use of non donor bank breast milk.  I agree to keep Arkansas Lactation informed of any physical condition or disability which may limit or prevent my participation in the use of non donor bank breast milk.  I acknowledge that employees and contractors of Arkansas Lactation including its owners, agents, directors, successors, and assigns, are not medical doctors nor are they engaged in the practice of treating or diagnosing medical injuries, diseases, or deficiencies. Accordingly, I expressly assume all risk of my participation in the use of non donor bank breast milk, and expressly waive any claims I may bring against Arkansas Lactation, its employees, owners, agents, contractors, officers, directors, or trainees, as a result of any injuries related to my participation in the use of non donor bank breast milk.

I hereby indemnify Arkansas Lactation, its directors, employees, volunteers and agents, for any injuries, liabilities, obligations, claims, costs or lawsuits arising from the use of this milk.