Mothers’ Milk Bank of North Texas
This information helps us identify which groups we serve well and who we need to work harder to reach.
Your answers will be kept private and will not affect your ability to donate or receive milk. Providing this information is optional.
Donor’s Healthcare Provider (OB doctor or Midwife):
Baby’s Health Care Provider (Pediatrician, Family Doctor, Nurse Practitioner):
DONOR’S MEDICAL HISTORY
DONOR HEALTH HABITS
Donor’s Obstetrical and Lactation History
The milk bank sometimes receives requests for milk from a mother on a restricted dairy diet for sensitive babies. Please let us know if you begin to eliminate dairy from your diet so we can separate this milk for those babies.
Baby's Medical History
I hereby certify that to the best of my knowledge I understand and have answered all questions truthfully. I have read the information provided to me regarding the spread of HIV and AIDS. I do not consider myself to be a person to be at risk for spreading HIV, AIDS or any other disease.
PERMISSION TO CONTACT HEALTHCARE PROVIDER
Donor Mother: Please complete the information below of this form giving us permission to contact the healthcare providers.
Medical information regarding donor mother and child
I authorize my healthcare provider to release the requested medical information to Mothers’ Milk Bank of North Texas.
- Genital herpes
- Blood transfusion in the last 12 months
- TB, hepatitis or prenatal viral infection
- Taking any medication on a regular basis? Please confirm any medications being taken.
Report test results below: (used as cross reference only - if test is not preformed mark as N/A)
- HIV-I & II
- HTLV I & II
- Hepatitis C
DONOR CONSENT FORM
- I have voluntarily chosen to donate my breastmilk to the Mothers’ Milk Bank of North Texas. I understand that I will not be paid for the milk I donate. I am also aware that my milk will not be sold, but a processing fee will be charged to the recipient of the milk. My milk or data about the milk may be used for research or educational purposes.
- I will make every effort to see that my milk is donated according to the instructions provided. I understand that it is my responsibility to notify Mothers’ Milk Bank of North Texas:
- a. if I, my baby, or a member of my household become ill
- b. when I need to take any new medications
- c. if a situation arises when I can no longer donate
- d. when I have any questions
- e. when I have been exposed to a contagious illness or disease
- I am also aware that once my milk has been donated, it becomes the property of Mothers’ Milk Bank of North Texas and may be shared with another nonprofit milk bank if there is a critical need.
- I have read and understand the Notice of Privacy Practices provided by MMBNT and I understand that all donor information is confidential.
- I hereby certify to the best of my knowledge that I understand and have answered all of the questions during my donor interview, including the health screening and medical history questionnaire, truthfully.
- I have reviewed and understand the information provided to me regarding the spread of HIV. I do not consider myself to be a person at risk for spreading HIV.
- I have read all of the information about HIV and the blood tests done for donors.
- I agree to have my blood tested as described in Blood Testing for Donors and I understand that I will be notified if the results are of medical significance and any medically significant results will be reported to the local health department, as required by law.
- I agree that my lab requisition can be sent to a third party company if they are drawing my labs at home or work for my convenience.
- I understand that I am encouraged to discontinue donating milk anytime my participation interferes with my own family’s needs.
- I understand that my approval as a milk donor does not indicate that my milk is safe to share or sell.
- MMBNT will not use my name or picture with prior notification and permission for the purpose of promoting the service of MMBNT or in a newsletter published by MMBNT.
- I understand that if I send photographs or cards to MMBNT they may be shared on social media unless otherwised specified.
- I understand that a small sample of my milk may be tested for common recreational drugs.
- I understand that I must communicate any changes to health & lifestyle every two-months.