Monday - Mother's Milk NZ Recipient Waiver

Disclaimer for use of donated breastmilk

Using screened donated breastmilk can be safe and hugely beneficial for both donors and recipient babies in the community. As an organisation it is important for us to provide as much information as we can to those involved in milk sharing through our network. Please read the following information and sign the disclaimer when you’re ready, you can save progress using the button at the bottom of the form. Please do not hesitate to contact us if you have any questions.

If we provide you with a local donor’s contact details, we kindly ask that you follow our 48-hour rule. This means that you have 48-hours to contact that donor to arrange to collect their milk. We prefer our wonderful donors to not be delayed, run out of freezer space or for milk to sit for too long, when we have a waiting list of desperate babies. Please let us know if you are having trouble arranging to pick up a donor’s milk, communication is key.

Please NOTE: Any shipping, packaging and ice or unavoidable travel costs (mileage @ 50c/km) will be charged to the recipient, If you are receiving donor milk from out of town, there will be a $5 shipping admin charge for you. There will also be a one off nominal handling admin fee of $10 added to all milk exchanges either local or national for each donor you recieve, to contribute towards operational costs. We require your waiver form to be signed and returned to us prior to any milk exchanging hands. This is to keep us all safe with a common agreement.

Raw frozen breast milk is the best milk option this is why we blood screen our donors. Mothers Milk NZ Trust recommends Flash Heating for pasturization of donated breast milk, should you wish to, but leaves the choice up to the individual. Please ask us for more information if you need it.

We obtain as much information as we can for you from the donor. Some of this information is in regards to medications and supplements. Please read the questionnaire and ask your health care professional if there are any medications you are concerned about. By signing this document, you are stating that you will consult with your health professional and accept milk with informed consent.

This document is not intended as medical advice. It was created as a tool for informed choice. Consult your healthcare provider, if you have questions about the safety of sharing breast milk.

Mothers Milk NZ Recipient Information v1.8

Donors are screened via regular (3 monthly) blood tests for the following blood borne viruses:

Hepatitis B ; Hepatitis C ; HIV ; CMV ; Syphilis ; HTLV 1 & 2

Your Name *

First Name Last Name

Your relationship to baby *

Mum Dad Grandparent Legal Caregiver

Mother's name, if available/applicable

First Name Last Name

Email *

example@example.com

Phone Number *

Address *

Street Address

Suburb

City

Post Code

Council Region

Please select from the drop down list. If you are unsure, just select unsure

Pasturising milk at home:

Mother's Milk NZ Charitable Trust recommends Flash Heating to home pasturize donor breast milk as a precautionary measure, but we leave the choice up to the individual.

The stove-top Flash-Heat method of pasteurization is recommended worldwide for home pastaurising, this link takes you to a description. It has been shown in international research, that this method can kill HIV, HTLV 1 & 2, E. coli, HIV, Staph aureus, Strep A & B and CMV while protecting important vitamins and nutrient composition of the milk.

Baby's name

First Name Last Name

Baby's date of birth *

Was Baby born before 37 weeks gestation? If yes, please provide details *

Does Baby have any current or past medical conditions? If yes, please provide details *

Does Baby have any dietary requirements? If yes, please provide details *

Do you have any special requests or requirements related to sourcing donated breastmilk for Baby? If yes, please provide details *

Are you comfortable receiving milk from a donor that has received a COVID19 vaccine? Please comment *

Are you comfortable receiving milk from a donor that is potentially a vCJD carrier (Variant Creutzfeldt-Jakob Disease - commonly called "Mad Cow Disease") who lived in the UK between 1980 - 1996 - Please select other if you need more information *

Yes No

Do you/the mother have any medical conditions which contributed to your search for donor milk? If yes, please provide details *

Have you received support from a breastfeeding specialist? If yes, please provide details *

If you've tried galactogogues, or milk supplements which may increase supply? If so, please share what you've tried and whether you think it helped.

Here are some places you can seek breastfeeding support:

Find a qualified LC NZ Lactation Consultants Association (find an LC near you)

Plunket can refer you to a Breastfeeding support

You can find details on the La Leche League NZ Website for all the groups around New Zealand

Auckland - Auckland Distric Healthboard / National Womens Health and Breastfeeding

Wellington - Newtown Breastfeeding and Parenting Support Centre

Canterbury - Canterbury Breastfeeding Support Services

Oamaru - The Milk Room

Otago and Southland - Breastfeeding Support Otago and Southland

Dunedin - The Breast Room

Invercargill - The Milk Room

Online resources:

Kellymom breastfeeding and parenting
La Leche League NZ
Lactation Lockdown on Facebook (Lactation Lock-down has been developed as a FREE breastfeeding service for families requiring support during the Lock-Down period in New Zealand due to Covid-19)

Please download for your reference

I am aware of the benefits of breast milk and the risks of receiving donor breast milk. *

Yes

I am aware the donor has been screened for blood borne viruses via blood tests, and other health risks have been assessed through completing a lifestyle questionnaire. *

Yes

I have seen the list of screening tests that are recommended, and I am aware that these are from international milk banking guidelines relating to the use of donor milk. *

Yes

I am aware that it is recommended that donor milk be flash heated as a secondary precaution, and acknowledge that I have received information on how to do this. *

Yes

I acknowledge that I will consult health professionals to raise any concerns I might have about the use of donor milk. *

Yes

If I NO LONGER NEED THE MILK that has been donated to me, and would like to share it with another family, I acknowledge that I must let Mother's Milk NZ know, and return it back through MMNZ so that it can be redistributed to someone on their list *

Yes

I agree that no money has been exchanged and no payment has been made for donated breast milk other than the admin fee and and shipping costs. *

Yes

I confirm that I fully understand all of the information that has been provided, and as a result, confirm that am in a position to make an informed choice about the use of donated breast milk. *

Yes

By signing this Disclaimer, I acknowledge and agree that Mother's Milk NZ Charitable Trust will in no way be liable for any harm or injury suffered by either myself of the baby named above, in relation to receiving and using breast milk I have been donated.

Today's Date *

Date

Signature *

Clear

Please tell us who referred you, if you were referred to MMNZ. Or where you found MMNZ.

When you submit this form (option below) you will be redirected to our COVID-19 declaration form. Please fill in and submit that also. Many thanks.

Mother's Milk NZ Recipient Waiver

Tell us about Baby

Tell us some more about you

Agreement