Lactation Services Billing Form

Lactation Services Billing Form
Submit billing information for lactation services rendered.
Client Full Name
First NameLast Name
Client Email Address
example@example.com
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Billing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Service
MonthDayYear
Date
Type of Lactation Service Provided
Session Duration (minutes)
Lactation Consultant's Name
Service Details or Notes (optional)
Lactation Services and Products
Sort By
Name: A to Z
Name: Z to A
Price: Low to High
Price: High to Low
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Consultation Fee
Fee for lactation consultation session.
$120.00

Breastfeeding Supplies
Nipple shields, breast pumps, or other supplies provided.
$35.00Quantity

Travel Fee
Fee for in-home or travel services, if applicable.
$25.00

Follow-Up Session
Additional follow-up lactation session.
$90.00Quantity

Total
$0.00
Preferred Payment Method
Other
Client Signature (Required for Acknowledgment)
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