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:

What county do you live in?:

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

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: Please review the full notice carefully: https://texasmilkbank.org/file_download/ff899dbb-ffa2-48ed-bee1-34a287bb6fb5. 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: