Form Wc-51 - Special Formula Request Form - Arkansas Department Of Health Page 2
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1
2Name of Infant/Child___________________________________________________________________Date of Birth_______________________
Formula
Descriptions for Use
Diagnosis
Duration & Amount
Oral Supplements (1-5 years
Oral motor feeding disorders; FTT from underlying
1, 2, 3, 4, 5, 6 month(s)
of age)
medical condition that increases calorie requirements
beyond what is expected
_________oz/day
Boost Kids Essential
—Nestle
FTT must be indicated by one or more of the
Nutren Junior 1.0 with Fiber
following:
—Nestle
Weight consistently below the 3
percentile
•
rd
for age;
Weight less than 80% of ideal weight for
•
height/age;
Progressive fall-off in weight to below the
•
3
percentile; or
rd
A decrease in expected rate of growth
•
along the child’s previously defined growth
curve irrespective of its relationship to the
3
percentile
rd
Tube Feeding (1-5 years of
Tube feedings; oral motor feeding disorders; medical
1, 2, 3, 4, 5, 6 month(s)
age)
conditions that increase caloric needs
Note: may prescribe for 6
_________oz/day
months duration.
Nutren Junior 1.0
—Nestle
Nutren Junior 1.0 with Fiber
—Nestle
Boost Kids Essential
—Nestle
* Indicates formula is available in powder only
Supplemental Foods
The participant will receive the supplemental foods listed below, appropriate to their WIC participant category, in addition to the WIC formula.
Please indicate any supplemental foods or restrictions not approved due to contraindications with the participant’s medical diagnosis.
WIC Participant Category
WIC Supplemental Foods Available
Do Not Give
Restrictions/Comments
Infants (6-12 months)
Infant Cereal
Infant Vegetables/Fruits
Children and Women
Milk
Cheese
Cereal
Juice
Eggs
Vegetables/Fruits
Whole Grains
Beans
Peanut Butter*
Canned Fish**
* Peanut butter will not be issued to children under 2 years of age.
** Exclusively Breastfeeding Women, Partially Breastfeeding Women of Multiples or Pregnant Woman with Multiples are the only WIC
participant categories eligible to receive canned fish.
Date:_____________ Medical Provider (Print):_____________________________Contact Phone Number: (
)_______________
Medical Provider Signature:_________________________________________________________
MD
PA
APRN
DO
(discipline of medical provider must be indicated)
LHU/WIC CLINIC USE ONLY:
Request received by:___________________________ Title:___________________________________ Date:____________
CPA reviewing request:_________________________________Title:____________________________ Date:____________
WIC-51 (R 3/16)
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