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Intake Pre-Screening

Thank you for considering donating your breast milk. At Vitalis, we recognize the incredible impact donor breast milk has on the health and lives of infants. We take the safety of donors, recipients, and the milk itself very seriously every step of the way. If you're interested in donating, please complete all required fields below. A member of our team will be in touch if your intake information aligns with our current donor needs.

Please note: Due to the volume of applications, we’re only able to follow up with those who meet our needs and pre-qualification criteria.

Name *

Phone number *

Email *

How old is your baby? *

What City and State are you located in? *

Approximately how much milk do you plan to donate? *

Are you willing to have your blood drawn to test for diseases? *

In the last 12 months, have you used tobacco, vapes, e-cigs, etc.? *

In the past 12 months have you used cannabis in any form? *

Do you consume alcohol? If yes, how often and how much? *

Have you taken any medicines, supplements, or vaccines while pumping? *

Have you ever been rejected from donating milk? *

I confirm that I have read and agree to the Terms & Conditions. Terms & Conditions *

By checking this box, I acknowledge that I have read and agree to the Privacy Policy *