Outpatient Pasteurized Donor Human Milk Interest Form

Pasteurized donor human milk (PDHM) for outpatients can be used as a bridge as milk supply increases. Talk with your baby’s provider about using pasteurized donor milk at home. If you and your provider agree that donor milk is needed an account for your family will be set up. The amount of donor milk for outpatients is dependent upon availability and hospitalized infants are prioritized. Donor milk that is available for outpatients in frozen 4oz. bottles at $19/bottle.
 
You will be contacted when your form is received to confirm availability, finalize order, and for payment information. Shipping costs are paid by the purchaser. Payment by credit card only. Hours: M-F, 8:00am – 4:30pm. Closed weekends and major holidays. For questions, call 763-546-8051. Once received, donor milk cannot be returned. Please complete below:

Date: 
Baby Name(s):  Date of Birth: 
  Gender:  

Birth Weight:    Premature?   Gestational age at birth: 
 
Reason for donor milk: 

How is infant currently being fed?:   Is the infant currently hospitalized?  Yes      No

Number of 4oz. bottles requested:                x $19/bottle = 

Contact Information:

First and Last Name(s): 

Relationship to Infant:   
                                            
Phone(s):   

Email address: 

 I consent to be contacted by text, phone, or email.
      Texting is an effective way to contact those interested in receiving donor milk. By checking this box, you are agreeing to be contacted by text.
       When receiving a text from MMBB, you may opt out by replying STOP at any time. Text HELP for assistance.
Home address:  
                                                     
City:      State:      Zip: 

Referred by:  

Clinic or Hospital Name:  

Health Provider: 

Optional Demographics: 
The following information is gathered to address equity and access issues to PDHM and will be aggregated without identifiers.

Recipient's Race, Ethnicity/Cultural Identity: (Select all that apply)
  Asian or Pacific Islander                                               Black African American or Immigrant African American
  Indigenous, Native American, or Alaska Native       Hispanic or LatinX
  White or Caucasian                                                       Additional race, culture/ethnicity not listed above: 
  Prefer not to answer

Primary language spoken in my home is:
  English           Spanish            Hmong             Somali           Arabic        Additional language spoken: 
  Prefer not to answer

Annual household income level:
  < $25,000      $25,000-$49,999       $50,000 - $99,999       $100,000 - $149,999       $150,000 - $199,999       > $200,000       Prefer not to answer



 
 
Thank You.  You should receive a reply in about 2 hours if submitted M-F, 8am-2pm.
 
This form is sent over a secure connection.
All of your answers will be kept confidential.