Once you fill out this form, our staff will:

  • contact you to answer any questions and finalize your order (within 1 business day)
  • verify your insurance eligibility and coverage
  • ship you your pump (free shipping!)
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Please send your breast pump prescription to Milk Moms: Fax 763-413-9741, Text 763-413-0129, Email [email protected].
  • This field is for validation purposes and should be left unchanged.