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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

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* 1. Please enter your contact information:

Requested By:

Practice Name:

Mailing Address:

Address 2:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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* 2. Fax number:

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* 3. Date of Request:

Month/Day/Year

Date

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

A Closer Look at Latch and its Impact on Breastfeeding

Blood Glucose in the Breastfed Neonate

Breastfeeding the Late Pre-Term and "Supposedly Term" Infant

Breast Pain in Lactation

Controversies in Parenting Advice: Breastfeeding, Pacifiers and Sleep

How to Increase Breastfeeding Success: What the Research Shows

Immunology of Human Lactation

Insufficient Weight Gain: is it intake or supply?

Medications and Breastfeeding

Multicultural Aspects of Breastfeeding

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* 5. Professional training options (continued):

Wellstart International's Lactation Management Self-Study Modules, Level 1 (revised)

Other (please specify)

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* 6. Professional education resources:

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

Breastfeeding Answers Made Simple (Mohrbacher)

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

Medications and Mothers' Milk (Hale)

Other (please specify)

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

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

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Breastfeeding Answers
Made Simple
(Mohrbacher)

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

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

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

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Medications
and Mothers' Milk
(Hale)

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

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* 7. Patient Materials

Amy Spangler's "What Breastfed Babies Do" DVD

Born and Raised the Vermont Way magazine

The Hospital Experience booklet

My Breastfeeding Checklist (St. Albans prenatal version)

My Breastfeeding Checklist (Middlebury prenatal version)

My Breastfeeding Checklist (Rutland prenatal version)

My Breastfeeding Checklist (St. Albans pediatric version)

My Breastfeeding Checklist (Middlebury pediatric version)

My Breastfeeding Checklist (Rutland pediatric version)

Plan for Success Poster 18 X 24 (OB/FP)

Plan for Success Poster 18 X 24 (Peds)

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Amy Spangler's
"What Breastfed Babies Do"
DVD

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

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Born and Raised
the Vermont Way
magazine

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

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Hospital Experience

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My Breastfeeding Checklist (prenatal version)

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My Breastfeeding Checklist (pediatric version)

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Plan for Success Poster
(OB/FP)

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Plan for Success Poster
(Peds)

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* 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.

Yes, please contact via e-mail.

Yes, please contact via phone.

Yes, please contact by mail.

No, thank you.

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* 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.

Yes

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* 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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* 1. Please enter your contact information:

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* 2. Fax number:

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* 3. Date of Request:

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

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* 5. Professional training options (continued):

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* 6. Professional education resources:

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Breastfeeding:A Guide for theMedical Profession(Lawrence & Lawrence)

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Breastfeeding AnswersMade Simple(Mohrbacher)

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

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Medicationsand Mothers' Milk(Hale)

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* 7. Patient Materials

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Amy Spangler's"What Breastfed Babies Do"DVD

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Born and Raised the Vermont Way magazine

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Hospital Experience

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My Breastfeeding Checklist (prenatal version)

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My Breastfeeding Checklist (pediatric version)

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Plan for Success Poster(OB/FP)

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Plan for Success Poster(Peds)

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

Question Title

* 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.

Question Title

* 10. Any questions? Please call the WIC Program at 802-388-4644 or contact us via e-mail at lori.dotolo@ahs.state.vt.usDo you have suggestions or feedback for the WIC Program? Please use the text box below. Thanks very much!

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

Breastfeeding Answers
Made Simple
(Mohrbacher)

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

Medications
and Mothers' Milk
(Hale)

Amy Spangler's
"What Breastfed Babies Do"
DVD

Born and Raised
the Vermont Way
magazine

Plan for Success Poster
(OB/FP)

Plan for Success Poster
(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.

* 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!