Language
English (US)
Dispensary Order Form
Name of the recipient
*
First Name
Last Name
Recipient date of birth
*
-
Month
-
Day
Year
Date
Parent or Guardian name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Signature
*
Please use your computer mouse or finger to sign
Clear
Number of 100ml/3.4 fl. oz. bottles needed
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Each 100ml/3.4 fl. oz. bottle is $14.00
If ordering more than 12 (twelve) 100ml/3.4 fl oz. bottles TOTAL (over recipient's lifetime), a prescription is required.
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Prescriptions must be written by a healthcare provider with prescriptive authority (physician, nurse practitioner, etc). The Milk Bank's form may be used or the provider's own prescription as long as it contains the recipient's name, birth date, date of the prescription, number of ounces needed (for example, 10oz per day for up to 2 weeks) and the reason donor milk is needed (for example, insufficient milk supply). Scan, photo, etc are ok.
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Dispensary Location
*
Please Select
Mid-Atlantic Mother’s Milk Bank
Lehigh Valley Breastfeeding Center
Your total:
Please use this total to make your payment after you click submit below.
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