Dispensary Order Form

Dispensary Order Form
I would like to:
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
Batch number: XXXXXX
Number of bottles: number
Batch number: XXXXXX
Number of bottles: number
Name of the recipient child

First NameLast Name
Recipient child date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.Format: (000) 000-0000.
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. Please note: The maximum order is 12 bottles, per baby, per lifetime without a prescription.
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.
Cancelof
Your total:
Please use this total to make your payment after you click submit below.
Don't forget a soft cooler bag to transport the milk home.
Should be Empty: