Dispensary Order Form
Name of the recipient
Recipient date of birth
Parent or Guardian name
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
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Number of 100ml/3.4 fl. oz. bottles needed
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.
Mid-Atlantic Mother’s Milk Bank
Lehigh Valley Breastfeeding Center
Please use this total to make your payment after you click submit below.
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