Referrals For Breastfeeding Support And Wic Services Form

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Georgia WIC Referral Form
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: ___________________________________________________
Clinic/Hospital/Medical Office Name:
To locate your County
Street Address:
Health Department,
City:
please visit
Zip Code:
(select “Clinic Listing”) OR
Phone Number:
call 1-800-228-9173
Fax Number:
Infants/Children Referral Data: (Complete Applicable Information)
Length/Ht: _____ in. Wt: ____ lbs. ____ oz.
Date: _____________
Hgb/Hct: ______
Date: __________
(Valid within 60 days of measurement)
(Valid within 90 days of measurement)
Birth weight: ______ lbs. ______ oz.
Birth Length: _______ in.
If premature, weeks gestation at birth: __________
Breastfeeding?:
Yes
No
Referral data provided by: (signature) __________________________________________
Date: _________________
Women Referral Data: (Complete Applicable Information)
Length/Ht: _____ in. Wt: ____ lbs. ____ oz.
Date: _____________
Hgb/Hct:_______
Date:____________
(Valid within 60 days of measurement)
(Valid within 90 days of measurement)
EDC: ________________
Last Wt Prior to Pregnancy: ______ lbs.
Multiple Gestation?:
Yes
No
Delivery Date: ______________
Last Wt Prior to Delivery: _______ lbs.
Breastfeeding?:
Yes
No
If Currently Breastfeeding:
Exclusively
Partially
Unknown
Breastfeeding follow-up needed:
Yes
No
Mother/baby separation
Latch-on issues
Milk supply concerns
Other____________________________________
Additional Comments/Details ________________________________________________________________________________
________________________________________________________________________________________________________
Referral data provided by: (signature) __________________________________________
Date: ____________________
Instructions & Resources for Use of This Form:
This form is intended for use as…
A medical data referral form for infants, children and women for the Georgia WIC Program
A breastfeeding support referral form for the Georgia WIC Program
A proof of identification for hospitalized newborn infants
We appreciate your cooperation and partnership in serving the Georgia WIC population.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees,
and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or
retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.),
should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through
the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:
, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested
in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Revised 9/2016
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