Place an Order

Place an Order

Use the form below for hospital or at home use:

New accounts: Submit the form below and a Medolac Representative will contact you within 24 hrs, M-F.
Existing accounts: Send us your completed Purchase Order: Fax: 866.239.3654 or Email: order@medolac.com

Home Use:
Please complete first section only and a Medolac Representative will contact you.

Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Describe your needs *

Hospital Use:
Billing Information

Account Type *

Contact Name *

First

Last

Job Title *

Email *

Legal Business Name *

DBA (if applicable) *

Primary Phone Number *

Extension *

Secondary Phone Number *

Extension *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Preferred Invoicing Method *

Preferred Payment Method *

Fed Tax ID Number *

Shipping Info

My shipping address is same as billing *

Yes No

Destination Name *

Contact Name *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Accounts Payable Contact

Name *

First

Last

Phone Number *

Extension *

Email *

Fax Number *

Purchasing Contact

Name *

First

Last

Phone Number *

Extension *

Email *

Fax *

Clinical Contact

Name *

First

Last

Phone Number *

Extension *

Email *

Fax *

Implicated Products Emergency Contact

Name *

First

Last

Phone Number *

Extension *

Email *

Fax *

Submit

CONTACT US:
Phone: 1(866) 599-7740
Email: info@medolac.com

Co-op Donor Milk is processed at the world's largest human milk bank. We offer the most affordable donor milk solutions for the Neonatal Intensive Care Unit, discharged infants who need donor milk for home use, and more. Explore the donor milk options Medolac has to offer today, offered by the world's leading milk bank for innovative human milk based nutritional products. With no shortages, and improved safety and quality Co-op Donor Milk is changing lives around the world. Learn more about milk banking, and donor milk by exploring our website or contacting us today.