1. Middlebury WIC Provider Materials Order Form 2.0

Breastfeeding resources are available to Middlebury area provider offices participating in the WIC Mother/Baby Breastfeeding Project.

If you have questions about the project or about using this order form, please contact the WIC Program in the Middlebury District Office.

Middlebury District Office WIC Program
Telephone: 802-388-4644 select option 3

Middlebury District Office breastfeeding designee
e-mail: jessica.doos@state.vt.us

This order form can be found here:
https://www.surveymonkey.com/s/Middlebury

1. Please enter your contact information:

2. Fax number:

3. Date of Request:

Month/Day/Year
/
/

4. Professional training options from the Physician Lactation Education Collaborative of Washington:

5. Professional training options (continued):

6. Professional education resources:

Breastfeeding:
A Guide for the
Medical Profession
(Lawrence & Lawrence)

Breastfeeding:<br>A Guide for the<br>Medical Profession<br>(Lawrence &amp; Lawrence)

Breastfeeding Answers
Made Simple
(Mohrbacher)

Breastfeeding Answers<br>Made Simple<br>(Mohrbacher)

Breastfeeding:
Natural, Biological,
Instinctual, Challenging
(WIC)

Breastfeeding: <br>Natural, Biological, <br>Instinctual, Challenging <br>(WIC)

Medications
and Mothers' Milk
(Hale)

Medications<br>and Mothers' Milk<br>(Hale)

7. Patient Materials

Amy Spangler's
"What Breastfed Babies Do"
DVD

Amy Spangler's<br>"What Breastfed Babies Do"<br>DVD

Born and Raised
the Vermont Way
magazine

Born and Raised <br>the Vermont Way <br>magazine<br>

Hospital Experience

Hospital Experience

My Breastfeeding Checklist (prenatal version)

My Breastfeeding Checklist (prenatal version)

My Breastfeeding Checklist (pediatric version)

My Breastfeeding Checklist (pediatric version)

Plan for Success Poster
(OB/FP)

Plan for Success Poster<br>(OB/FP)

Plan for Success Poster
(Peds)

Plan for Success Poster<br>(Peds)

8. Practice Services
To request a follow-up visit, please check the box below. WIC Program staff will contact you to set up an appointment.

9. Would you like to sign up for brief updates on breastfeeding in Vermont via e-mail? These updates will occur no more than 4 times per year.

10. Any questions? Please call the WIC Program at 802-388-4644 or contact us via e-mail at lori.dotolo@ahs.state.vt.us

Do you have suggestions or feedback for the WIC Program? Please use the text box below. Thanks very much!

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