Forms

This form below may be used to refer patients to the WIC Program and to communicate changes in patient health information. The information provided on this form will be used by a WIC nutritionist to determine nutrition care and provide nutrition counseling

WIC-Medical Documentation Form


Use the form below to request exempt formulas, WIC-Eligible Nutritionals, standard formulas for infants unable to tolerate solid foods, and supplemental foods for patients with qualifying medical conditions. If you have questions or need additional clarification, please contact the SBH WIC Offices

WIC Special Formula Form


Use the form below to request pre-screening for the WIC programs

SBH WIC Pre-screening Form