Breast Pumps | HME Specialists | Delivered to Your Door

Expected Due Date or Baby’s DOB*

Email Address:*

Have your insurance card ready!

Mother’s Name*

First Last

Mother’s DOB*

Mother’s Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Mother’s Insurance Company*

Policy #*

Mother’s Doctor Name*

Doctor Ph #*

Doctor Fax#

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Choose your preferred breast pump and accessories:

With the Spectra® S2 Plus™ you will receive:
• Two (2) 24mm Spectra Breast Flanges
• Two (2) 28mm Spectra Breast Flanges
• Two (2) Spectra Tubing
• Two (2) Spectra Duckbill Valves
• Two (2) Spectra Backflow Protectors. Includes silicone membrane, uppercase, and lowercase for each Backflow Protector
• Two (2) Spectra Wide Neck Storage Bottles. Includes nipple, cap, disc, and cover for each bottle One (1) Spectra 12V AC Power Adapter/Charger

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