Free Breast Pump Order Request, DPH 40052A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health DPH 40052A (Rev. 06/08)

STATE OF WISCONSIN Bureau of Community Health Promotion

Project Number:

WISCONSIN WIC PROGRAM BREAST PUMP ORDER REQUEST

Order Deadline (check one) 1st Qtr 7-Dec 2nd Qtr 7-Mar 3rd Qtr 7-Jun 4th Qtr 7-Sep

Project Name:
Completion of this form is voluntary. Information collected will be used to order and ship client material. Mail completed form to Wisconsin WIC Program, Nutrition Section, PO Box 2659, Madison, WI 53701-2659, or fax to: 608/266-3125. Note any shipping changes at the bottom of the form.

Manufacturer/Product Medela Hospital Grade Electric Pump (ea) Personal Electric Pump with battery (3/case)* Double Pumping Accessory Kit (20/case)* Manual Pump (20/case)* Manual Pump (20/case)*

Product Name

Quantity in units

Manufacturer/Product Ameda

Product Name

Quantity in units

Lactina Select Pump In Style Personal Double Pump Lactina double kit WIC Harmony Spring Express (WIC) manual pump

Hospital Grade Electric Pump (ea) Personal Electric Pump (ea) Double Pumping Accessory Kit (10/case)* Manual Pump (20/case)*

Elite Purely Yours with tote and kit Dual Hygienikit Ameda One-Hand Optional Accessories

Optional Accessories Personal Fit X-Lg 30 mm Breastshields (6 pks of 2 ­ order per box) Boxes

Custom Breast Flange (30.5 mm/28.5 mm Inserts) (6 pair per box ­ order per box)

Boxes

*Order the number of each kit/pump needed; do not order in case quantities.
Note any shipping changes for breast pumps: Address: City/State/Zip: Telephone: Contact: Contact: