Wic Health Care Referral printable pdf download

NEW JERSEY WIC HEALTH CARE REFERRAL

FOR

PREGNANT WOMAN

BREASTFEEDING WOMAN (Up to 1 Year Postpartum)

NON-BREASTFEEDING WOMAN (Up to 6 Months Postpartum)

Name

Birthdate

Address

Telephone Number

Women, infants and children

MUST be present at every WIC

ANTHROPOMETRIC AND LABORATORY DATA

certification appointment.



Height and weight measurements must be taken <30 days prior to WIC appointment.

Bring:



At least ONE blood test of Hemoglobin, Hematocrit or Erythrocyte Protoporphyrin (EP) is needed

∙Proof of your family's income

to determine nutritional risk of all women. The blood test must be taken <90 days prior to WIC

∙Proof of where you live

appointment.

∙Proof of ID for every person



PREGNANT WOMEN need blood test which was done during pregnancy.

∙Health care referral form filled



POSTPARTUM WOMEN (breastfeeding and non-breastfeeding) need blood test which was done

out

after delivery.

∙Immunization records of

infant/child

Blood Test Date

Hemoglobin

Hematocrit

Lead (if available)

Other

g/dl

gm/dl

CALL for an appointment with

Height

Pre-Pregnancy Weight

WIC office checked:

(Healthcare provider:

inches

lbs.

Check WIC office for patient.)

# Wks. Gest.

Measurement Date

Weight

Blood Pressure

FIRST

Burlington County

PRENATAL

lbs.

mm/Hg

609-267-4304

CHECK-UP

Children’s Home Society

# Wks. Gest.

Measurement Date

Weight

Blood Pressure

MOST

of NJ

RECENT

lbs.

mm/Hg

609-498-7755

CHECK-UP

East Orange

MEDICAL HISTORY

973-395-8960 (8963)

Delivery Date

Woman’s Weight Just Prior

# Weeks Gestation at

Gloucester County

to Delivery

Delivery

Estimated

856-218-4116

lbs.

Actual

Jersey City

Date Last Pregnancy Ended

No. Previous Pregnancies

No. Previous Live Births

201-547-6842

Newark

Check all of the following which apply and give a brief

973-733-7628

Explanation

explanation:

North Hudson

_________________________________

Hx of low birth weight infant(s) (<5.5 lbs.)

201-866-4700

Hx of premature infant(s) (<37 weeks gestation)

_________________________________

NORWESCAP

Hx of infant(s) >9 lbs at birth

908-454-1210

_________________________________

Hx of miscarriage(s)/stillbirth(s)/abortion(s)

Ocean County

_________________________________

732-341-9700 X 7520

Hx of or planned C-section

_________________________________

Multiple pregnancy or recent multiple birth

Passaic

973-365-5620

Medical problems (e.g. Diabetes, Hypertension,

_________________________________

Preeclampsia, Eclampsia)

Plainfield

_________________________________

908-753-3397

Disability which may compromise adequacy of diet

_________________________________

Social or environmental condition which may

Rutgers

973-972-3416

compromise adequacy of diet

_________________________________

Substance use (e.g. alcohol, drugs, cigarettes, pica)

St. Joseph

_________________________________

973-754-4575/4730

Vitamin/mineral supplement or medicine prescription

Special formula prescription and medical reason for

TriCounty/Gateway CAP

_________________________________

Main Office:

its necessity

_________________________________

856-451-5600

Other pertinent health/medical data

Atlantic Office:

609-246-7767

AUTHORIZATION RELEASE

Camden Office:

I, the undersigned, give permission to my provider to give the WIC Program any required medical information.

856-225-5050

Signature of Patient Being Referred

Insurance Carrier and Member ID Number

Trinitas

908-994-5141

Signature of Physician or Health Professional

Date

VNA

732-471-9301

Name and Address of Physician or Clinic (Print or Stamp)

STATEWIDE

1-800-328-3838 (24 Hrs.)

Telephone Number:

WIC-41

APR 16

This institution is an equal opportunity provider.

Wic Health Care Referral

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