Breast Pump Request Form

Please fill out the form to reserve or purchase a breast pump.  If you want it shipped, please include your shipping address in the Shipping/Pick Up Information section. A prescription is required for BP if the baby is not born. Please indicate pick up location -- Fairport or South Ave (city of Rochester). Please contact us with any questions. If you reseving this product a few months before the anticipated pick up date, please confirm a week in advance if you are planning to be here on the date selected. Thank you!

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General Information
Shipping / Pick Up Information
Date you plan to pick up the pump or date to be shipped. Will accommodate if you call with a new date. * If shipped, please allow for 1-2 business for product to arrive. Out of stock may affect ship date.
Date you would like the the pump to be shipped. Please allow for 1-2 business for product to arrive. Out of stock may affect ship date.

If you chose "Plese Ship to Me", please add your preferred shipping address below.

Medical Information
Please select the breast pump you would like from following products

About the Affordable Care Act

The Affordable Care Act has a provision for breast feeding support, supplies, and counseling. While the provision does not specify coverage of electric or manual pumps, purchase or rental, some insurance carriers are covering electric pumps while others are covering manual pumps at little to no cost to the member. Let NuLife Medical Supply help you determine your insurance coverage and which device will work best for you.

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