Compression Socks, Maternity Support Band and Postpartum Compression Garment Order Form

Did you order a breast pump or supplies from The Breastfeeding Shop already?*
YesNo
Insurance Provider*opt1opt2opt3

D.O.B of Patient

must be the sponsor's social security number.

Sponsor D.O.Bt

Best way to Contact You?*

Phone CallEmailopt3

How are you submitting the prescription to us?*

I will upload or attach to this form.opt2opt3

Prescription - Your prescription can be for any of the items : Compression Socks, Maternity Support Band or Postpartum Compression Garment

must provide if you would like us to contact your doctor.*

Do you have a secondary insurance?*

YesNo

Compression Socks, Maternity Support Band and Postpartum Compression Garment - please indicate what you need.*

Maternity BeltCompression SocksPostpartum Compression Garment
What Size Maternity Belt Do You Need*
opt1opt2opt3
What Size Postpartum Compression Garment Do You Need
opt1opt2
What Size Compression Socks do you need*
opt1opt2opt3
[signature signature-522 cols:500 rows:200 color:#000 background:#fff]Use your mouse or finger to draw your signature above. Use your mouse or finger to draw your signature above. Assignment of benefits and release of information. By signing this you authorize your insurance company who is responsible for paying for my care to pay benefits on my behalf directly to The Breastfeeding Shop for any products or services that were rendered to me by The Breastfeeding Shop. I also authorize The Breastfeeding Shop to request, on my behalf, all public and private insurance benefits for products provided to me by The Breastfeeding Shop. I hearby authorize The Breastfeeding Shop to release my medical records to any person, organization, company and/or agency which is or may be 1. Involved in providing care for me or 2. liable for any portion of the payment of the charges for such products and services.