BREAST PUMP REQUEST -

APPLY FOR A FREE ELECTRIC BREAST PUMP & MATERNITY GARMENTS TODAY!

Mom's Full Name *

Correo Electrónico *

Número de Teléfono *

Mom's Birth Date *

Baby's Due Date *

Do you have MEDICAID? *

YesNo

OBGYN Clinic's Information *Clinic's Name

‎City

‎Clinic's Phone Number

‎Doctor's Name

I WOULD LIKE: ( ALL ITEMS ARE AT NO COST WITH MEDICAID )

BREAST PUMP

SUPPORT BAND ( During Pregnancy )

Support Band SizeOnly available 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 sciatica

COMPRESSION SOCKS

Compression Socks Size

Benefits 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 day

Language Preference

EnglishSpanish

Please provide a good mailing address for delivery of products:

Street Address *

Apartment, suite, etc

City *

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.

Please expect a text from RSQ Medical Equipment within 24 hours regarding your request. To opt out of texting, please indicate other preferred method of contact:

APPLY FOR A FREE ELECTRIC BREAST PUMP & MATERNITY GARMENTS TODAY!

Do you have MEDICAID? *

I WOULD LIKE: ( ALL ITEMS ARE AT NO COST WITH MEDICAID )

Language Preference

Please provide a good mailing address for delivery of products:

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.**

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