MyChart -

Thank you for your interest in donating breastmilk. By completing this form, you will be initiating the process to donate breastmilk to the WakeMed Mothers’ Milk Bank. Your generous donation will directly benefit NICU babies all along the east coast.

Step 1: Complete this online Breast Milk Donation Form

Step 2: Receive a call from our Donor Intake Coordinator

Step 3: Complete Donor Intake Forms

-More in-depth questionnaire
-Donor Consent Form
-Release form(s) that give us permission to reach out to your doctor(s)

Step 4: Have blood drawn at a WakeMed or LabCorp location

Step 5: Become an approved milk donor and make your first donation!

Please expect to hear from us within two business days of form submission. If you have any questions, please feel free to contact us directly by calling 919-350-8599, option 1 or emailing us at mothersmilkbank@wakemed.org.

First Name

Last Name

Name you prefer to be called. (If same as first name, leave blank)

Preferred Pronouns

Email Address

Phone Number

Can we leave a voicemail at this number?

Street Address

Apt

City

State

Zip

Do you speak English?

If no, preferred language

Donor Date of Birth

Baby Date of Birth

Is your baby currently living?

Have you donated with us before?

Approximately how many ounces do you have to donate?

What type/brand of containers or bags is your milk stored in?

What type of pump are you using to extract milk?

Has this pump been used by anyone other than yourself?

Are all the containers or bags labeled with the day they were pumped?

Are your hands and pump parts washed prior to each pump session?

After pumping, how long does your milk stay out at room temperature before freezing or refrigerating? Placing in a cooler with ice packs is considered refrigerating.

How long does your milk stay in the refrigerator before freezing?

What type of freezer is your milk stored in?

How old is the oldest milk you plan on donating?

Have you had any thrush or yeast infections of the breast, or breast or nipple infections such as mastitis while pumping?

Have you received blood or blood products in the last 6 months?

Have you ever been told you cannot donate milk or blood?

Since delivery have you consumed any alcohol?

How often do you consume alcohol?

When you have alcohol, how many drinks do you have in one sitting?

How long after having an alcoholic drink do you wait to pump and SAVE milk?

Do you or any one you are regularly exposed to smoke tobacco, use nicotine products, marijuana, electronic cigarettes or chew tobacco?

Have you ever lived in the United Kingdom, France or Ireland?

Have you ever received blood or blood products in the United Kingdom, France or Ireland?

Would you consider yourself or your sexual partner(s) at high risk for exposure to HIV or Hepatitis?

Have you or your sexual partner(s) been stuck with a contaminated needle within the last 12 months?

Since giving birth what medications have you taken? Please list all prescription, over the counter, supplements, herbals, and vitamins.

Have there been any fevers in your home since the birth of your baby?

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