Breast Pump Supply Order Form

Only WIC staff with approved WIC agencies may use this form to order breast pumps and supplies.

  • Only approved WIC agencies that contract with the Washington State Department of Health may use this form to order clinic Breast Pump Supplies.
  • The Washington State WIC Program only pays for items listed on this order form.
  • Send a copy of the packing slip or confirmation within 3 days of receiving your order
    to WICBreastpumps@doh.wa.gov or fax # 360-236-2320.
  • Attention: You must provide all the contact information. If you do not, we cannot process your order.

For persons with disabilities, this document is available on request in other formats.
To submit a request, please contact 1-800-841-1410 (TDD/TTY 1-800-833-6388).

Information collected via this form may be subject to release in accordance with RCW 42.56 (Public Records Act).

1. Contact Information - Required Information
Contact First and Last Name
Contact Email Address (enter your complete and valid Email)
Contact Phone Number
Agency Name
Clinic Name
Clinic FedEx Shipping Address (No PO Boxes)
City, State, Zip Code


Note:  New Items, once available, will not ship until current breast pump stock is depleted.

2. Electric Multi-User Pumps
63.00.524
Ardo Bellis multi-user includes cooler bag
*1 pump each
each
10-0044s3
Hygeia EnJoye Cordless multi-user electric breast pump only
*1 pump each No case
each
40-0003
Hygeia EnJoye Cordless Multi-user Power Cord Only
*1 power cord each
each
PA209DM-RT12
Rumble Tuff Breeze Pro Electric multi-user electric pump only (includes carrying tote with cooler compartment)
*1 pump each
each
OPERA
Unimom Opera Hospital Grade Electric breast pump
*4 pump per case No case
case
3. Personal-Use Breast Pumps
63.00.511
Ardo Alyssa personal pump with pumping bag, cooler bag, cooling elements, 2 silicone inserts (22mm) and PAS set (26mm)
*1 pump each
each
10-0313
Hygeia PRO Dual-Phase personal use pump with PAS, backpack, cooler and cold pack
*1 pump each
each
53250
Lansinoh SmartPump 2.0 Bundle Dual-Phase breast pump with w/deluxe tote and personal accessory set
also 6 AA batteries portable power options - *1 pump each
each
53351
Lansinoh SmartPump 3.0 Bundle Dual-Phase breast pump with w/deluxe tote and personal accessory set
rechargeable lithium battery - *1 pump each
each
53751
Lansinoh Discreet Duo Pump personal-use electric wearable pump
*Order by the case / 8 units per case.
case
53750
Lansinoh Wearable Pump personal-use electric pump
*Order by case / 1 unit per case
case
101041359
Medela Pump In Style w/MaxFlow personal-use electric breast
*1 pump each
each
101040485
Medela Pump In Style w/MaxFlow Replacement Tubing
*Order by case / 6 tubes per case
case
MM011091-TG
Spectra S1 Plus with Tote and Cooler and all components (arrives in large box)
*Order by case / 1 pump per case
case
ZOMEE Z2-E0603
Zomee Z2 double electric personal use pump includes 2 (21mm) Flex Breast Shields, 2 (24mm) Flex Breast Shields
*Order by case /12 pumps per case
case
ZFHF
Zomee, Wearable Pump includes 2 (17mm) Breast Shield Inserts, 2 (21mm) Breast Shield Inserts, 2 (25mm) Breast Shield/Flange, collection containers, adjusters
*Order by case /10 pumps per case
case
4. Manual Breast Pumps
20-0117
Hygeia 2 Phase (One-hand) manual breast pump w/detachable flanges
* 1 case contains 20 pumps
case
20-0070
Hygeia (Two hand) manual breast pump- piston pump
* 1 case contains 20 pumps
case
50700
Lansinoh Silicone Breast Pump (Milk Collector)
* 1 case contains 12 pumps
case
101029270
Medela Harmony (One-hand) w/PersonalFit Flex Breast Shield
* 1 case contains 20 pumps
case
6107293W
Medela (Two-hand) Manual pump w/piston cylinder (limited stock)
* 1 case contains 20 pumps
case
5. Breast Pump Flanges
6LH-3456
Ardo Silicone Inserts (13 mm) fits in Ardo 26mm breast shells
* order by the case / 1 case contains 25 pairs **Works with All 24-28mm Flanges
case
6LH-3460
Ardo Silicone Inserts (15 mm) fits in Ardo 26mm breast shells
* order by the case / 1 case contains 25 pairs **Works with All 24-28mm Flanges
case
6LH-3464
Ardo Silicone Inserts (17 mm) fits in Ardo 26mm breast shells
* order by the case / 1 case contains 25 pairs **Works with All 24-28mm Flanges
case
63.00.397
Ardo Silicone Inserts (18 mm) fits in Ardo 26mm breast shells
* order by the case / 1 case contains 20 pairs **Works with All 24-28mm Flanges
case
30-0172
Hygiea XS-Small- Flange (10 mm)
* order by the case / 1 case contains 10 flanges
case
30-0168
Hygeia Small Flange (13 mm)
* order by the case / 1 case contains 10 flanges
case
30-0169
Hygeia Small Flange (15 mm)
* order by the case / 1 case contains 10 flanges
case
30-0170
Hygeia Small Flange (17 mm)
* order by the case / 1 case contains 10 flanges
case
30-0165
Hygiea XS-Small- Flange (20 mm)
* order by the case / 1 case contains 10 flanges
case
10-0119
Hygiea Soft flange (25 mm insert- fits in medium flange)
* order by the case / 1 case contains 20 flanges
case
30-0006
Hygeia Medium Flange (27 mm)
*order by the case / 1 case contains 10 flanges
case
30-0044
Hygeia Large Flange (30 mm)
*order by the case / 1 case contains 10 flanges
case
30-0045
Hygeia X- large flange (31 mm)
* order by the case / 1 case contains 10 flanges
case
53510
Lansinoh ComfortFit Flanges (21 mm)
* order by the case / 1 case contains 6 flanges
each
101028982
Medela 87086 Small Flanges Personal Fit Shields (21 mm)
* order by the case / 1 case contains 12 flanges
case
101028984
Medela 87087 Medium Flanges Personal Fit Shields (24 mm)
* order by the case / 1 case contains 12 flanges
case
101028986
Medela 87077 Large Flanges Personal Fit Shields (27 mm)
* order by the case / 1 case contains 12 flanges
case
101028988
Medela 87079 XL Specialty Flanges Personal Fit Shields (30 mm)
* order by the case / 1 case contains 12 flanges
case
101028989
Medela 87094 XXL Flanges Personal Fit Shields (36 mm)
* order by the case / 1 case contains 12 flanges
case
ZAW-2
Pumpin Pal Flange - Zomee Flange Adapters (works with Unimom/Rumble Tuff)
* order by the case / 1 case contains 10 Pairs of Adapters
case
SFBXS-10
Pumpin’ Pal X-Small Single Flange w/collar (Fits 15-18mm)
* order by the case / 1 case contains 10 flanges
case
SRXS-10
Pumpin’ Pal X-Small Retail Package Pairs (Fits 15-18mm)
* order by the case / 1 case contains 10 Pairs
case
SRS-10
Pumpin’ Pal Small Retail Package Pairs (Fits 19-23mm)
* order by the case / 1 case contains 10 Pairs
case
SFBS-10
Pumpin’ Pal Small Single Flange w/collar (Fits 19-23mm)
* order by the case / 1 case contains 10 flanges
case
SFBM-10
Pumpin’ Pal Medium Single Flange (Fits 24-28mm)
* order by the case / 1 case contains 10 flanges
case
SRM-10
Pumpin’ Pal Medium Retail Package Pairs (Fits 24-28mm)
* order by the case / 1 case contains 10 Pairs
case
SRL-10
Pumpin’ Pal Large Retail Package Pairs (Fits 29-32mm)
* order by the case / 1 case contains 10 Pairs
case
SFBL-10
Pumpin’ Pal Large Single Flange (Fits 29-32mm)
* order by the case / 1 case contains 10 flanges
case
SFBXL-10
Pumpin’ Pal X-Large Single Flange (Fits 33-40mm)
* order by the case / 1 case contains 10 flanges
case
SRXL-10
Pumpin’ Pal X-Large Retail Package Pairs (Fits 33-40mm)
* order by the case / 1 case contains 10 pairs
case
WICEB-1
WIC Essentials Bundle includes 20 XS, 20 SM, 20 M, 10 LG & 10 XL Flanges
* order by Each / 1 Bundle Each
each
PA905C3-RT10
Rumble Tuff (13mm) Breast Shields
* order by the case / 1 case contains 20 flanges
case
PA905C4-RT10
Rumble Tuff (15mm) Breast Shields
* order by the case / 1 case contains 20 flanges
case
PA905C5-RT10
Rumble Tuff (17mm) Breast Shields
* order by the case / 1 case contains 20 flanges
case
PA905C1-RT10
Rumble Tuff (19mm) Breast Shields
* order by the case / 1 case contains 20 flanges
case
70-PA000NS-RT05
Rumble Tuff (Flange Fit Ruler 5) description
*order by the case / 1 case contains 5 flange Fit Rulers
case
PA905C2-RT10
Rumble Tuff (21mm) Breast Shields
* order by the case / 1 case contains 20 flanges
case
MM012716-S
Spectra Wide Breast Flange Set 16mm (XS)
* order by Set / includes 1 flange in a set
set
MM012753-S
Spectra Wide Breast Flange Set 20mm (S)
* order by the case / 1 case contains 20 flanges
case
ZS15MM-Set
Zomee Flex Breast Shields, Size 15mm
* order by Set / 1 set includes set of 2
set
ZS17MM-Set
Zomee Flex Breast Shields, Size 17mm
* order by Set / 1 set includes set of 2
set
ZS19MM-Set
Zomee Flex Breast Shields, Size 19mm
* order by Set / 1 set includes set of 2
set
ZS21MM-Set
Zomee Flex Breast Shields, Size 21mm
* order by Set / 1 set includes set of 2
set
ZSHFCCI-17MM
Zomee Inserts for Silicone Hands Free Collect, Size 17mm
* order by Set / 1 set includes 2 packs
set
ZSHFCCI-19MM
Zomee Inserts for Silicone Hands Free Collect, Size 19mm
* order by Set / 1 set includes 2 packs
set
ZSHFCCI-21MM
Zomee Inserts for Silicone Hands Free Collect, Size 21mm
* order by Set / 1 set includes 2 packs
set
6. Pump Personal Accessory Sets (PAS)
63.00.555
Ardo Double Clinic Pump Set (PAS) kits Works with All Ardo breast pumps (including Bellis)
* 1 case contains 18 double sets
case
20-0075
Hygeia Personal Accessory Set (PAS) breast pump kits Works with EnDeare, EnJoye, & Lactina multi-user pumps
* 1 case contains 20 kits
case
PA91900-0210
Rumble Tuff Expression Collection Combo Kit for multi-user (PAS) pump kits with Tote Works with Rumble Tuff pumps includes (1) Flange Fit Ruler, (1) Tote
* 1 case contains 30 kits
case
UODBSK24MM
Unimom Detachable Double Breast Shield Kit 24mm Personal Accessory Set (PAS) breast pump kits Works with OPERA multi-user pump
*1 PAS kit each
each
7. Breast Pump Bags/Cases
63-00.328
Ardo Hard Case for multi-user pumps *1 case contains 2 Hard Cases
case
50-0072
Black insulated tote for multi-user pumps
* 1 case contains 20 tote bags
case
PA91003-RT10
Rumble Tuff Carrying Tote with Cooler Compartment
* 1 case contains 24 tote bags
case
8. Pump Milk Storage Bags, Collection Cups, Nursing Pads, and Pump Cleaning Supplies
826199
CaviWipes Surface Disinfectant Premoistened Wipes 160 count canister Unscented (Mfr #13-5100)
* Order by Case/12 containers per case- WIC Staff Use Only
case
826199
CaviWipes Surface Disinfectant Premoistened Wipes 160 count canister Unscented (Mfr #13-5100)
* Order by Each/ 1 container per case- WIC Staff Use Only
each
210928
CaviCide Surface Disinfectant Cleaner Alcohol Based Pump Spray (Mfr #13-1024)
* Order by case / 12 each per case/ 24 oz. Bottle-For WIC Staff Use Only
case
OG Breast Milk Chiller
OG Breast Milk Chiller – Future So Bright White
* Order by case/ 6 items per case
case
Demigoddess Mini Chiller
Demigoddess Mini Chiller – Starry Night (Shimmering Black)
* Order by case/ 6 items per case
case
20473
Lansinoh Breastmilk Storage Bags
* Order by case/ 100 Count/12 packs per case
case
53441
Lansinoh Milk Storage Bags Adapter (Supports Lansinoh Storage bags work with other pumps)
* Order by case/ 24 (2 count) packs per case
case
10-0290
Milkies Storage Bags
* Order by case/ 100 pks per case/2000 bags per case
case
ZAW-2
Pumpin’ Pal Zomee Pump Adapter
* Order by case/10 pair per case
case
10-0333
Washable Nursing Pads
* 1 case contains 100 pks of 4 pads each
case
SHFCC
Zomee Silicone Hands-free Collection Cups, Set of 2 includes (24/28mm) Breast Shields - Works with Medela, Hygeia, Lansinoh, Ardo, Spectra
* Order by case - 16 cups/case
case
9. If you would like to receive email confirmation of your submission, please enter your email address in the space below.
 
Email for confirmation (optional):