Form Wic-349 - Referral To The Virginia Special Supplemental Nutrition Program For Women, Infants And Children (Wic)

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Referral to the
Virginia Special Supplemental Nutrition Program
for Women, Infants and Children (WIC)
The following medical information is needed by the WIC Program. Please complete as much
information as you can in order to assist your patient with the WIC Program’s application process.
Applicant’s Name: _________________________________________ DOB: _______________
Date of Exam: __________________________Length/Height: ________________________
Weight: _____ Birth Weight (if under 2 yrs. of age): ______ Birth Length (if under 2 yrs. of age): _____
If applicant is 9 months or older: Hgb: _________________ or Hct: ___________________
EDD (if pregnant): ________________________ or Actual Delivery Date: _________________
Please document any nutrition-related medical conditions: ______________________________
_____________________________________________________________________________
Healthcare Provider’s signature: __________________________ ___________________
Healthcare Provider’s Phone Number: _________________________________________
The Virginia WIC Program provides Ross Similac Advance and Ross Similac Isomil Advance.
If a special formula is needed, please complete the WIC-395 Form – Request for Special Formula.
Contact your local WIC office for a copy of this form or to answer your questions. You may visit our web
site to print the WIC-395 Form in your office.
Your appointment or your child’s appointment is scheduled for
______________ at __________.
1. You must bring with you:
proof of income, such as pay stubs, Medicaid card, Food Stamp letter
proof of identity, such as your baby’s crib card, social security card or your driver’s license
proof of residency, such as a utility bill or other item with your name and street address
2. You must bring your child if the appointment is for him or her.
3.
If you or your child have been to the doctor within 60 days prior of this scheduled appointment,
please have your doctor fill out this form and we will not repeat the measurement of height, weight,
or blood work. This will help make your clinic visit easier. Thank you.
Local agency street address, city and telephone number
This institution is an equal opportunity provider.
WIC-349, Revised 07/06

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