Breast Pump Through Insurance

Thank you for visiting Baby Pavilion, while others won't help you, we'll get you the supplies you need.

TRICARE policies permits only 1 replacement Kit per birth. So if you received any flanges or tubing, you won't be able to get more. Fortunately, TRICARE does permit you to receive 2 new valves and 90 milk storage bags every 30 days.

Name*

First NameLast Name

Phone Number*

E-mail*

Shipping Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Mother's DOB*

Date

DBN #: (Back of your card, 11 digits )*

Baby's Birthday*

Date

Doctor's Name*

First NameLast Name

Where did you get your pump?*

How did you find us?*

If you aready receved any flanges or tubing, we won't be able to get a Kit, but we can still ship you replacement valves and bags.

Did you already receive any additional Flange or Tubing?*

YesNo

If you said no and we ship you more, you will be charged. Norw worries though, you can still get valves and bags at no charge. :)

Pump Type?*

SpectraMedela

Spectra Accessories?*

Spectra Full Kit (Valves, Flanges, Tubing, Bottles, Caps)...if you have not already received.2 Spectra ValvesNo Accessories

Flange Size?*

20mm (Spectra)24mm (Spectra)28mm (Spectra)32mm (Spectra)

Medela Accessories?*

Medela Full Kit (Valves, Flanges, Tubing, Bottles, Caps)...if you have not already received.2 Medela ValvesNo Accessories

Flange Size?*

What type of Bags?*

100 Mother-K (10oz)80 Kiinde Twist (6oz)None

Comments

Signature

MOTHER'S INFORMATION

BREAST PUMP ACCESSORIES