APPLY FOR A FREE ELECTRIC BREAST PUMP & MATERNITY GARMENTS TODAY! Personal InformationMom's Full Name *Email Address *Phone Number *I consent.By checking this box, you consent to SMS terms and conditions. You'll receive SMS and emails regarding your order. Message and data rates may apply. To opt-out at any time reply ‘STOP’ to any of our messages.To opt out of texting, please indicate other preferred method of contact:Date Of Birth *Please put your date separated by slashesLanguage PreferenceEnglishSpanishEstimated Baby's Due Date *Please put your date separated by slashesInsurance InformationPlease select your insurance. *SelectWellpointParklandCook Children's Health PlanSuperior Health PlanAetna Better Health PlanMolina Healthcare of TexasCHIP PerinatalRight Care by BSWTexas Medicaid (TMHP)FirstCareDriscoll Health PlanCommunity FirstTricare / HumanaBCBS TXCignaOtherOther InsuranceInsurance ID NumberOBGYN InformationOBGYN Clinic's InformationClinic's NameDoctor's NameClinic's Phone NumberCityProduct RequestI WOULD LIKE: ( ALL ITEMS ARE AT NO COST WITH MEDICAID )BREAST PUMPSUPPORT BAND ( During Pregnancy )Benefits of Support Bands:• Helps to disperse the weight of your growing baby • Increases stability • Alleviates pain • Decreases SI joint pain • Lowers round ligament pain • Reduces pressure on the bladder • Supports prenatal activities or exercises • Corrects posture • Reduces sciaticaSupport Band SizeXS ( Pre-Pregnancy Pant Size: 00 - 0 )S ( Pre-Pregnancy Pant Size: 2 - 4 )M ( Pre-Pregnancy Pant Size: 6 - 12 )L ( Pre-Pregnancy Pant Size: 14 - 18 )XL ( Pre-Pregnancy Pant Size: 20 - 26 )Only available during pregnancy*COMPRESSION SOCKSBenefits of Compression Socks:• Prevents swelling • Reduces discomfort • Increases blood circulation • Prevents or minimizes risk of varicose and spider veins • Helps prevent blood clots • Lowers your risk of deep vein thrombosis (DVT) • Assists with long days on your feet • Increases overall comfort throughout the dayCompression Socks SizeS (Ankle: 6.5" - 8.5" / Calf: 11" - 16.5 ")M (Ankle: 8" - 10" / Calf: 12" - 17.5 ")L (Ankle: 9" - 11.5" / Calf: 13" - 19 ")XL (Ankle: 11" - 15" / Calf: 17" - 23 ")POSTPARTUM RECOVERY SUPPORT GARMENTBenefits of Postpartum Recovery Support Garment:• Provides gentle compression & support to reduce swelling, soreness, and pain • Stabilizes the abdomen, lower back, and hips for improved posture • Increases overall mobility • Tightens and tones belly, hips, waist, pelvis, and lower backPostpartum Recovery Support Garment SizeXS ( Pre-Pregnancy Pant Size: 00 - 2 )S ( Pre-Pregnancy Pant Size: 4 - 6 )M ( Pre-Pregnancy Pant Size: 8 - 10 )L ( Pre-Pregnancy Pant Size: 12 - 14 )XL ( Pre-Pregnancy Pant Size: 16 - 18 )2XL ( Pre-Pregnancy Pant Size: 20 - 22 )BLOOD PRESSURE MONITORPlease provide a good mailing address for delivery of products:Street Address *Apartment, suite, etcCity *State *ZIP / Postal Code *I understand that Medicaid will pay for one electric breast pump. Any other electric breast pumps I received will be an out-of-pocket expense.**I acknowledge.SUBMIT APPLICATION Like us on Facebook!
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