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

Mothers’ Milk Bank of North Texas (MMBNT) understands that medical information about clients is personal and we are committed to protecting this information. This notice describes how medical information about clients in our office may be used and disclosed, and how clients can get access to this information. We also describe client rights and certain obligations we have regarding the use and disclosure of medical information. Please review the full notice carefully: https://texasmilkbank.org/file_download/inline/6e1ed393-6617-42a0-be2e-5a1bf877745d

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: