Monday, December 24, 2012

Formula and Pacifier Refusal Form (Breastfeeding)

This form is provided here as an example on how to be concise, yet specific, and firm yet not hostile. This form is not intended to replace legal advice and you should always consult your own legal assistant if you have questions or concerns.

 Formula and Pacifier Refusal Form

Attention: Staff, Physicians, Nurses and other personnel at:

Facility Name:__________________________________________________________ Address:_______________________________________________________

This is a formal refusal to consent to infant formula, glucose water or any other forms of artificial feeding. You are hereby notified that our child, _____, is NOT to be offered any of the above mentioned options.

This also serves as a formal refusal to consent to the use of pacifiers, fingers or other objects for suckling comfort. Bring the child, ____, to the parents for milk and comfort.

If complications arise requiring additional assistance, the mother, ____, will work with a lactation consultant to create a specific health plan and that plan will be shared with staff immediately.


Mother: _________
Father: __________


Note that the magic words in the medical setting are: I refuse to consent. We refuse consent. I do not consent. Those are the words that work for the lawyers and the ones they are trained to hear.

Anything that is open to interpretation or that turns your stance into an opinion should be avoided. Avoid words such as: Prefer, wish, desire, want, like, hoping, counting on, interested in, etc.

If your consent will change based on circumstances, then specifically mention those circumstances. Avoid phrases such as, "Unless medically necessary" or "Except in emergencies" because those are open to interpretation and represent your automatic approval instead of requiring them to come to you in that moment.

Additionally, if you remain concerned about the behavior of the staff or you are receiving harassment, consider placing a card in the baby's isolette with a summary of the above.

"Hi, my name is _______. My parents refuse to consent to formula, sugar water and pacifiers for me. If you have questions, refer them to my mother in room: _____ and father at: ________." 

You can also consider screenprinting a basic baby onesie with something loud and simple such as, "BREASTFEEDING ONLY" or "NO PACIFIERS OR BOTTLES."
Here are some cute stickers I found on zazzle:

Circumcision Refusal Form:

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