MILK DROP-OFF FORM

Donor milk safety is our priority. Milk pumped since our last date of contact with you cannot be used until this form is complete. Please carefully consider the following questions. Contact milkdrop@mnmilkbank.org if you have any questions or call 763-290-1882.

 




Please answer all of the following questions:
 
1. Was I or any member of my household sick during the period of time this milk was collected? *
 
 
**If you answered yes to the question above. Did you take anything to manage symptoms or prevent illness in yourself? (If yes, please provide the name and active ingredients below)
 
 
2. Since my last contact with the milk bank, have I taken any NEW prescribed or over-the-counter medicines (e.g., antibiotics, cold/flu or allergy medications), supplements (e.g., vitamins, herbal) or remedies or received any vaccinations? 
 
 
3.Have I, or my partner(s), had any new infection risk through new sexual partners, needle stick (e.g., piercing, tattoo, acupuncture, transfusion) or other lifestyle change (e.g., drug use, alcohol consumption, jail)? 
 
 
​​​​4. Is this my final donation?​​​
 
 
 
If you answered YES to any of the above questions, please give a detailed explanation below including the start and stop dates for new medications. It is mandatory to report these changes, regardless of whether or not the donation pile will contain milk expressed on these dates. We appreciate your cooperation in maintaining the safety standards of donor milk for fragile infants. A donor coordinator may reach out to you with further questions.
If you took any new supplements, please provide photos of the containers. Select and upload images by clicking "Choose Files" below. Capture the front and back of all supplements, ensuring ingredient lists are easy to read. Multiple files can be uploaded at once.


If you took a new supplement but no longer have the original container, please provide a website link to the exact product.



Thank You for your Liquid Gold!
 
 
This form is sent over a secure connection.
All of your answers will be kept confidential.