Confirmation of services received

Please complete this form to confirm that you have received lactation services by Margaret Rodeghier, CLC.

If you feel that services rendered were incomplete or insufficient, please still complete this form for time spent and then email help@milk.solutions for additional support, concerns, and feedback.

Name Name First Last
Email
Phone Phone - ### - ### ####
Date of initial in-person or virtual services Date of initial in-person or virtual services / MM / DD YYYY

If you do not remember the exact date of your appointment, please enter approximate date to the best of your knowledge.
How long was your in-person appointment?
How long was your virtual appointment? (Does not apply towards phone/text follow up support)
Approximately how much time was spent with follow up questions/check ins/support? This includes text, messaging, and phone call support.
I confirm that these time estimates are to the best of my knowledge, and were provided by Margaret Rodeghier, CLC

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.