DH 3075: Florida WIC Program Medical Referral Form

DH 3075 PDF Details

Even if you have not identified a health problem, refer the client to the WIC program.

Measurements: height and weight measurements are to be taken no more than 60 days before the client's WIC appointment.

Infants: a bloodwork value is required once during infancy between 6 to 12 months of age and once between 1 to 2 years of age.

Children 2 to 5: a bloodwork value is required once a year unless the value is abnormal, then a bloodwork value is required in 6 months.

Stamp: stamp the form with the office stamp or the health professional's stamp.

Completed form: give this completed form to the client or parent/guardian to bring to the WIC certification appointment, or mail/fax it to the local WIC agency.