Mothers’ Milk Bank of North Texas:

Lactation Support Inquiry Form

If you are experiencing an urgent lactation need, please complete this inquiry form. Our on-site IBCLC may be able to support you or direct you to a more immediate resource.

Reasons you might need 1 on 1 support:

Baby not gaining weight/not back to birth weight at 2 weeks
NICU discharge
Twins
Latch problems

*While we wish we could accommodate all individual lactation inquiries, due to scheduling capacity, you may be referred to other resources.

We will respond to your submission as soon as possible, but within 24-48 business hours. We are open Monday through Friday, 9:00am - 4:30pm.

Contact Information

Mother's First Name:

Mother's Last Name:

Mother's DOB:

Phone number:

Email:

This information helps us identify which groups we serve well and who we need to work harder to reach. Your answers will be kept private and will not affect your ability to receive lactation support.

Race

Ethnicity: Hispanic or Latino?

Language

Highest Education Completed

Household Income

Health Insurance

How did you hear about us?
If you were referred by a specific person or community organization, list who:

Baby's Information

Baby's Full Name:

Baby Date of Birth:

At what week was baby born?:

Current weight:

Birth weight:

Breastfeeding Information

Please describe your current breastfeeding challenges:

Please describe any health concerns and medications for mother:

Please describe any health concerns and medications for baby:

Are you currently receiving breastfeeding support?

Yes No

If yes, with who?

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.

I acknowledge that I have received a copy of the agency’s Notice of Privacy Practices. I also acknowledge that by providing my contact information, I am giving permission to Mothers' Milk Bank of North Texas staff to contact me to follow up on this inquiry submission, via email or phone, which may include leaving a voicemail or receiving automated text message reminders on the phone number provided.

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

Signature:

Date: