Hospital Screening Form



Name of Hospital:

 

Level of NICU 
 
Beds in NICU
 
Other type of unit
 
 
 
 

Primary Contact Info: 

First Name
Last Name
Title
Phone #1   
Phone #2
Fax
Email


 

Secondary Contact Info:

First Name
Last Name
Title
Phone #1   
Phone #2
Fax
Email

 



Shipping Information:
Hospital FedEx #   
Hospital UPS#   
Hospital Shipping Address:
Hospital Name
Attn: 
Address 1
Address 2
City
State
Zip
Phone # for Queries
Email Addresses to send tracking info:
Email 1
Email 2
Email 3





Billing Information:
Is facility part of a larger hospital system?

If yes, please name: 
 
Department to be billed  
Contact First Name
Contact Last Name
Billing Contact Title
Billing Contact Phone
Billing Contact Fax
Email addresses for invoices
Email address for invoice queries
Billing Address Line 1
Billing Address Line 2
City
State
Zip




Marketing Contact (if applicable):
 
First Name
Last Name
Title
Phone
Fax
Email
 

 

Neonatologists and other Health Care Providers interested in Donor Human Milk:


Contact 1:

First Name
Last Name
Title
Phone   
Email

 

Contact 2:
First Name
Last Name
Title
Phone   
Email


Contact 3:

First Name
Last Name
Title
Phone   
Email


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