Vital Milk can provide your patients with a free in-home visit by Certified Lactation Counselor (CLC) upon delivery of an insurance-covered breast pump. We provide this service to offer evidence-based breastfeeding support and also to ensure our clients know how to use an electric breast pump properly to establish, maintain and/or increase their milk supply.  Upon receipt of this form: Vital Milk will contact your patient, provide information about the different features of each breast pump and schedule their delivery at a time that is convenient for them. Free shipping is also an option.

To place orders, providers can:


*This form is hosted securely on the Microsoft Azure cloud platform, which is PCI (DSS) Level 1 and HIPAA compliant.