8669 Commodity Circle, Suite 490 • Orlando, FL 32819
Web: milkbankofflorida.org P:407-248-5050 • F: 407-370-4340 • E: INFO@milkbankofflorida.org

Please read the pamphlet Welcome Donor for MMBFL and our HIPAA Privacy Statement before completing the form. When asked, please indicate the dates you took medications, vitamins or herbal remedies. The form does not save your work, so it is important to have everything ready before you start to complete the questionnaire. You can save your answers, just before you sign and submit, as an html document or print as a pdf. Call or text us at 407-248-5050 if you have questions or concerns. Thank you for your time and generosity.



D. DONOR HEALTH HISTORY - Mother's Obstetrical and Lactation History
E. DONOR HEALTH HISTORY – Lifestyle Answering YES to a question does not necessarily exclude you as a donor.

If yes, please list the NAME of the medicines taken, the DOSAGE, and DATES taken.

It is very important for us to know what medications you were taking during that time. This includes prescription and over-the-counter medications such as birth control pills, antibiotics, laxatives, stool softeners, allergy, diabetic, blood pressure, cholesterol, asthma, or pain medications.

If yes, please list the NAME of the herbal remedies or supplements taken, the DOSAGE, and DATES taken.

Select all tobacco types that apply:



All prospective breastmilk donors must have blood testing.

Testing is done at no cost to you, the donor. The lab requisition form will be mailed to you and the Milk Bank will be billed.

The human immunodeficiency virus (HIV) test detects antibodies to HIV or the AIDS virus. While the risk of acquiring HIV/AIDS is very low for any infant receiving another mother's milk, at this point it is reasonable not to accept milk from anyone who has ever been exposed to the virus.

While the test for antibodies to the HIV/AIDS virus detects almost everyone who carries the antibody to the virus, it occasionally is false positive.

Other viruses which breastmilk donors are screened for are: Hepatitis B, Hepatitis C, HTLV-1 and 2 (Human T-cell Lymphotropic Virus), and Syphilis. If your screening tests show positive for any of these viruses, the lab will perform confirmatory tests at no expense to you and the milk bank will be billed.

These results, if reactive, are reportable to the State Department of Health. Donors will receive their test results via the U.S. Postal Service.


I voluntarily choose to donate my breastmilk to Mothers’ Milk Bank of Florida, a not-for-profit organization accredited by the Human Milk Banking Association of North America (HMBANA). I understand that I will not be paid for the breastmilk that I donate. I am also aware that my milk will not be sold, but a processing fee will be charged to the recipient of the milk. My donated milk and non-identifiable data about my milk may be used for research purposes.

I understand that all my donor information is confidential.

I have received a copy of the MMBFL HIPAA Privacy Statement.

I am aware that once my milk has been donated, it becomes property of Mothers’ Milk Bank of Florida and cannot be returned to me. If my milk is dispensed to another HMBANA Milk Bank, my records will be shared with them.

I will make every effort to see that my breastmilk is donated according to the instructions provided. I understand that it is my responsibility to notify Mothers’ Milk Bank of Florida:

  • If I, my baby, or a member of my household, become ill.
  • When I take any medications or herbal or dietary supplements.
  • When I have questions about being a breastmilk donor.
  • When I have been exposed to a contagious illness or disease.
  • When I experience a decrease in my milk production.

I understand that I am encouraged to discontinue breastmilk donation, any time my participation interferes with my own family's needs.

I hereby certify to the best of my knowledge that I understand and have answered all of the questions in my donor screening packet truthfully. I have reviewed and understand the information provided to me regarding the spread of HIV. I do not consider myself to be a person at risk for spreading HIV.

I have read all of the information about HIV and the blood tests for breastmilk donors. I agree to have my blood tested as described. I understand that I will be notified if the results are of medical significance.

I understand that a sample of my breastmilk will be tested for bacteria after pasteurization.

I understand that acceptance by Mothers' Milk Bank of Florida as a donor is in no way an indication that my milk is safe to share with individuals outside the milk bank process. Milk banks take several steps to assure the safety of donor breastmilk beyond the health screening of the donor. Therefore, it is a misrepresentation to use the milk bank screening process to guarantee the safety of my breastmilk for a recipient, if it has not gone through processes similar to those used by a milk bank.

Donor Signature: (sign with mouse, finger or stylus)