Service Request Form

Choose Your Service

Tell us which product or service you're interested in so we can help you get started.
Which stated do you live in?
Unfortunately, the services offered through this form are currently only available to residents of Iowa, Minnesota, and Wisconsin.

Looking for a breast pump? Our breast pump program serves a much larger area! If you're interested in ordering a breast pump through insurance, please complete our Fast Track Form to get started.
Which services are you requesting?
Breast Pump
Breast pump requests are handled through our Fast Track Form.

If you're interested in ordering a breast pump through insurance, please complete our Fast Track Form to get started.
Car Seat
Which insurance plan do you have?
Unfortunately, our car seat program is only available to members of the insurance plans listed above. If your insurance is not listed, we are unable to fulfill your request.

We apologize for the inconvenience and appreciate your interest in Milk Moms.
Who is the car seat for?
Unfortunately, our Car Seat Program is only available to patients who are currently pregnant and requesting a car seat for their expected baby.

If you're requesting a car seat for a child who has already been born, we are unable to fulfill your request through this program.
What is your due date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Member ID
Maternity Items
Which maternity items would you like to order?
What is your due date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pelvic Floor Therapy - Flyte
Which insurance plan do you have?
Unfortunately, our Pelvic Floor Therapy Program is only available to members of the insurance plans listed above. If your insurance is not listed, we are unable to fulfill your request.

We apologize for the inconvenience and appreciate your interest in Milk Moms.
Resupply
Breast pump replacement parts and milk storage bags are available through our Resupply Program.

If you're interested in receiving these supplies through insurance, please complete our Resupply Request Form to get started.

Your Information

Tell us a little about yourself and your insurance so we can check your benefits and process your request.
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Company
Member ID
Insurance Group #
Who is the policy holder?
Please describe the relation to the policy holder
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have any other insurance?
Other Insurance Company
Other Insurance ID #
How did you hear about Milk Moms?
Please describe "other"

Prescription Information

Let us know if you already have a prescription for these items. If you do, we'll provide instructions for sending it to us. If not, we'll help request one from your healthcare provider.
Do you have a copy of your prescription for these items?
Please send your prescription to us either through secure email or text: Email: orders@milkmoms.com | Text: 763-259-8824
Provider Name
The name of your OB provider/midwife (whoever would be signing the prescription).
Provider Facility
The name of the clinic/hospital/midwifery/etc that your provider works at.
Provider Facility City
The name of the city your provider is located.
Provider Phone Number
The contact number for your provider/facility.Format: (000) 000-0000.

Complete Your Request

You're almost done! Please review the required consent and authorization, and sign below to submit your request.
Communication Consent
Consent and Authorization Form
By signing below, I acknowledge that I have reviewed and agree to the Consent and Authorization Form.
Should be Empty:

Choose Your Service

Breast Pump

Car Seat

Maternity Items

Pelvic Floor Therapy - Flyte

Resupply

Your Information

Prescription Information

Complete Your Request