Dispensary Order Form

I would like to:*

Pickup donor milk from the milk bank or a dispensary.My child is being discharged from the hospital and the unit is sending us home with bottles of donor milk.My child is still in the hospital, but does not meet hospital criteria so we are purchasing donor milk.

Dispensary location*

What hospital is your child being discharged from?*

Hospital name

Name of facility supplying the milk*

Hospital name or Milk Bank

Hospital location*

Ex: St. Luke's Allentown

What are the batch numbers of the bottles that you are taking home (if known)? This info will be given to you by the unit or you can find it on the bottle.

Batch number: XXXXXX
Number of bottles: number

Name of the recipient child*

First NameLast Name

Recipient child date of birth*

Date

Parent or Guardian name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / 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

Number of 100ml/3.4 fl. oz. bottles needed*

Each 100ml/3.4 fl. oz. bottle is $15.00

If ordering more than 12 (twelve) 100ml/3.4 fl oz. bottles TOTAL (over recipient's lifetime), a prescription is required.

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.

Your total:

Please use this total to make your payment after you click submit below.