Breast Pump Supply Order Form

• 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.

Step-by-step guide on how to complete this order form.

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).