WIC Medical Referral Forms

Massachusetts Women, Infants, & Children (WIC) Nutrition Program Medical Referral Forms for healthcare providers.

Medical Referral Form

The Medical Referral Form is a form you fill out that helps identify the medical or nutritional risk factor(s) needed for enrollment in WIC. Although the Medical Referral form is not mandatory, it helps WIC serve your patients better by:

• Documenting a medical or nutritional risk to facilitate WIC enrollment
• Avoiding duplicate bloodwork and anthropometric data collection
• Enabling WIC staff to conduct immunization screening
• Enabling WIC staff to provide nutrition counseling and referrals based on your concerns and recommendations

Download: 

• Medical Referral Form for women and infants (PDF) | (Doc)
• Medical Referral Form for infants and children (PDF) | (Doc)