Payment for THREE 100 ml bottles of outpatient donor milk.

Parent Agreement for purchase of donor human milk:

Parent understands purchase is limited to 3 bottles per infant as indicated on prescription. Additional milk must be obtained from Northwest Mothers Milk Bank by calling 503-469-0955. Once milk is purchased, milk cannot be returned. If milk purchase exceeds order limit, Northwest Mothers Milk Bank will refund any overpayment.

Outpatient Donor Milk (300 mls)

Name: Outpatient Donor Milk (300 mls)
Brand: Northwest Mothers Milk Bank

$45.00

Donor Milk Distribution Site

Infant's Full Name and Mother/Parent's Name on Prescription

Initial to confirm you have read the Parent Agreement

Quantity

This is a one time order! For additional orders please obtain a prescription from your baby's provider and contact Northwest Mothers Milk Bank to check availability of milk at 800-204-4444 or 503-469-0955.

Outpatient Donor Milk (300 mls)

One time order.