Human Milk Donation Form
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Thank you for your interest in donating your milk. By completing this form, you will be initiating the process to donate your surplus milk to The New York Milk Bank.

Our screening process includes submission of this form, completion of an interview and application, submission of signed consents from your healthcare providers, and a blood test provided at no cost to you. Following approval, your generous milk donation will directly benefit babies in NICUs in the Tri-State area.


Please expect to hear from us within two days of form submission. If you have any questions or concerns, please feel free to contact us directly by calling 212-956-6455, or emailing us at donatemilk@nymilkbank.org.

 

Name
 
 
 
 


Email Address
 
  

Phone Number
 
  
Can we leave a voicemail at this number?

 

Approximately how many ounces do you have to donate?
 
  

Are all the containers or bags dated with the day they were pumped?
 
  

What is the earliest pump date of the milk you plan to donate?
   
Since giving birth, what medications have you taken?
Please list all over the counter and prescription medications.

 
 
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