Wic Medical Documentation Form
Download a blank fillable Wic Medical Documentation Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Wic Medical Documentation Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
22
Georgia WIC Medical Documentation Form
Special Food Substitutions and Referrals for Breastfeeding Support and WIC Services
Patient’s First & Last Name: ________________________________________ Date of Birth (MM/DD/YY): ____/____/____
(For Infants/Children) Parent/Caregiver’s First & Last Name: ___________________________________________________
Medical Office/Clinic Name:
To locate your
Street Address:
County Health Department,
City:
please visit
Zip Code:
Phone Number:
or call 1-800-228-9173.
Fax Number:
Referral Data: (Complete Applicable Information)
(Instructions on Reverse.)
Length/Ht: _____in. Wt: ____lbs. ____oz. Date: _____/_____/_____
Hgb/ Hct: ______ Date: _____/_____/_____
Birth weight: ______lbs. ______oz.
Birth Length: _______ in.
If premature, weeks gestation at birth: __________
(Prenatal) EDC: _____/_____/_____
Last Wt Prior to Pregnancy: ______ lbs.
Multiple Gestation?:
Yes
No
(Postpartum) Delivery Date: ____/____/____ Last Wt Prior to Delivery: ______ lbs.
Yes
No
Breastfeeding?:
Yes
No
Exclusively
Partially
Unknown
(Infant/Child) Breastfeeding?:
If Currently Breastfeeeding:
Yes
No
Breastfeeding follow-up needed:
Mother/baby separation
Latch-on issues
Milk supply concerns
Other____________________________________
only, please stop here and have the health professional who collected the above referral data
If using this form to provide referral data
sign and date the line below.
Referral data provided by: (signature) __________________________________________
Date: _____/_____/_____
CHILDREN (≥12 Months Old): Authorization of Special Food Substitutions
(Instructions on Reverse.)
Note: Special food substitution will replace all or part of the child’s milk/cheese allowance provided by the Georgia WIC Program.
Medical Condition(s) Justifying Food Substitution: ___________________________________________________________
Food Substitution Authorized (check one):
Soy Milk
Tofu
Extra Cheese
Planned Length of Use: ____________ Comments: ___________________________________________________________
Provider’s Signature/Title:* _______________________________________________________________________________
Print Name: ______________________________________________________________________ Date: _____/_____/_____
*Note: In accordance with federal regulations, the Georgia WIC Program only accepts medical documentation signed by the following
providers: physicians (MD, DO), physician assistants (PA, PA-C), and nurse practitioners (e.g., NP, APRN, CPNP, CNP, PNP, CNNP).
WOMEN: Authorization of Special Food Substitutions
(Instructions on Reverse.)
Note: Special food substitution will replace all or part of the woman’s milk/cheese allowance provided by the Georgia WIC Program.
Medical Condition(s) Justifying Food Substitution: ____________________________________________________________
Food Substitution Authorized (check one):
Extra Tofu
Extra Cheese
Planned Length of Use: _____________ Comments: ____________________________________________________________
Provider’s Signature/Title:* _________________________________________________________________________________
Print Name: _______________________________________________________________ Date: _____/_____/_____
*Note: In accordance with federal regulations, the Georgia WIC Program only accepts medical documentation signed by the following
providers: physicians (MD, DO), physician assistants (PA, PA-C), and nurse practitioners (e.g., NP, APRN, CPNP, CNP, PNP, CNNP).
Page 1 of 2
Revised June 2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical