WIC Participant Electric Breast Pump Referral - OU Medicine 2026

1. Click ‘Get Form’ to open the WIC Participant Electric Breast Pump Referral in the editor.
2. Begin by entering your personal information in the designated fields, including your name, phone number, and address.
3. Indicate which breast pump you have received instructions for by checking the appropriate box next to either 'Medela Lactina Electric Breast Pump' or 'Medela Symphony Electric Breast Pump'.
4. Ensure that you sign and date the form where it states 'WIC Breastfeeding Mother’s Signature' to certify that you have received instructions on the pump's operation.
5. If someone else will be picking up your breast pump, fill in their name in the permission section and sign again with the date.
6. Finally, ensure that the International Board Certified Lactation Consultant completes their section, including their signature and date.

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