Fast Track Order Form

Once you fill out this form, our staff will:

  • Contact you to start your order and help you pick out a pump (within 1 business day)
  • Verify your insurance
  • Ship you your pump (free shipping!)

  • Demographic Information

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Insurance Information

  • MM slash DD slash YYYY
  • Order Details

  • (Only available for certain insurance plans)
  • Please send your breast pump prescription to Milk Moms: Fax 763-413-9741, Text 612-757-5455, Email [email protected].
  • This field is for validation purposes and should be left unchanged.