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: