DONOR HUMAN MILK

INQUIRY FORM -

To receive donor human milk for your baby, we need to see if baby meets certain qualifications before dispensing milk. Please fill out the following information:

Parent/Guardian Information

Parent/Guardian First Name:

Parent/Guardian Last Name:

Relationship to baby:

Home phone:

Cell phone:

Email:

Are you located in the Dallas/Fort Worth area?

City:

State:

Preferred Language:

Baby Information

Baby's Date of Birth:

Baby's Full Name:

Does your baby have any current medical conditions that impact his/her feeding?

Yes No

If yes, please list all medical diagnosis.

Is the mother/birthing parent currently breastfeeding/pumping?

Yes No

Why are you interested in receiving donor milk?

Notice of Privacy Practices

At Mothers’ Milk Bank of North Texas (MMBNT), we value our customers, employees, and those who interact with us as well as their information, their privacy, and their trust. This Privacy Policy explains how we collect, use, disclose, and safeguard information in connection with our business, breastmilk donation, testing, storage, distribution activities, and community programs. This Policy also applies to information collected online from users of our website, www.texasmilkbank.org, and explains how we collect, use, and protect that information. Please review the full notice carefully: https://texasmilkbank.org/file_download/ff899dbb-ffa2-48ed-bee1-34a287bb6fb5.

Please keep this notice for your records.

AGENCY
Mothers’ Milk Bank of North Texas
7617 Benbrook Parkway
Fort Worth, Texas 76126
817-810-0071

Once form is submitted, we will reach out to you after reviewing the informaiton provided. Please note, our operating hours are Monday - Friday, 9am - 4:30pm.

Signature of legal guardian:

Date: