Breast Pump Supply Order Form

Order form for breast pumps and supplies.

Only approved WIC agencies that contract with the Washington State Dept. of Health may use this order form to order clinic pump orders.

The Washington State WIC Program only pays for items listed on 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).

All comments received, including attachments and other supporting materials, are part of the public record and may be subject to public disclosure under RCW 42.56 (Public Records Act).

CONTACT INFORMATION - REQUIRED

Contact First and Last Name
Contact Email Address
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.

Electric Multi-User Pumps

10-0044s3	Hygeia EnJoye Cordless multi-user electric breast pump only *1 pump each		NO CASE
40-0003	Hygeia EnJoye Cordless Multi-user Power Cord Only *1 power cord each		each

Personal-Use Breast Pumps

10-0302	Hygeia Evolve Dual-Phase breast pump with PAS, backpack, cooler and cold pack *1 pump each	each
10-0313	Hygeia PRO Dual-Phase personal use pump with PAS, backpack, cooler and cold pack *1 pump each (unavailable until older stock depleted)	each
53250	Lansinoh SmartPump 2.0 Bundle Dual-Phase breast pump with w/deluxe tote and personal accessory set *1 pump each	each
101041359	Medela Pump In Style w/MaxFlow personal-use electric breast *1 pump each	each

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	each
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

Breast Pump Flanges

30-0165	Hygiea XS-Small- Flange (20 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
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

BREAST PUMP PERSONAL ACCESSORY SETS (PAS)

20-0075

Hygeia Personal Accessory Set (PAS) breast pump kits Works with EnDeare, EnJoye, & Lactina multi-user pumps
* 1 case contains 20 kits

case

BREAST PUMP BAGS/CASES

50-0072

Black insulated tote for multi-user pumps
* 1 case contains 20 tote bags

case

BREAST PUMP MILK STORAGE BAGS & NURSING PADS

20473	Lansinoh Breastmilk Storage Bags * Order by case/ 100 Count/12 packs per case	each
53441	Lansinoh Milk Storage Bags Adapter (Supports Lansinoh Storage bags work with other pumps) * Order by case/ 24 (2 count) packs per case	each
10-0290	Milkies Storage Bags * Order by case/ 100 pks per case/2000 bags per case	case
80-0036	Washable Nursing Pads * 1 case contains 100 pks of 4 pads each	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):

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).

All comments received, including attachments and other supporting materials, are part of the public record and may be subject to public disclosure under RCW 42.56 (Public Records Act).