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WIC Pediatric Referral Mobile App

The WIC Pediatric Referral mobile app provides a simple way for a health care provider to refer infants and children to the WIC program.

Participation in the program helps give mothers, infants and children access to affordable, nutritious foods, along with access to nutrition education and health care services. The WIC referral form includes questions about the child's health, mom's feeding habits and more. Once completed, the referral can be emailed directly to your local WIC office for evaluation.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the WIC Pediatric Referral Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    WIC Agency:

  • Ico textbox

    WIC ID #:

  • Ico statictext

    SECTION I: Complete this section to assist the patient with WIC eligibility, WIC services, and ap...

  • Ico textbox

    PATIENT NAME

  • Ico date

    DATE OF BIRTH:

  • Ico textbox

    CURRENT HEIGHT/LENGTH: _________ inches (within 60 days)

  • Ico textbox

    CURRENT WEIGHT: _____ lb _____ oz (within 60 days)

  • Ico decimal

    CURERNT BMI: BMI percentile: ______ % (within 60 days)

  • Ico date

    MEASUREMENT DATE:

  • Ico textbox

    BIRTH WEIGHT/LENGTH: _________ lb ________oz / ________ inches

  • Ico statictext

    HEMOGLOBIN OR HEMATOCRIT TEST is required every 12 months when normal and every 6 months when abn...

  • Ico textbox

    Hemoglobin (gm/dl) or Hematocrit (%)

  • Ico date

    Lab Result Date

  • Ico textbox

    LEAD TEST (recommended at 1-2 years of age): _______ mcg/dL

  • Ico statictext

    IMMUNIZATIONS are up-to-date:

  • Ico checkbox

    Yes

  • Ico checkbox

    No

  • Ico checkbox

    Not available

  • Ico statictext

    BREASTFEEDING ASSESSMENT (birth to 12 months):

  • Ico checkbox

    Fully breastfeeding

  • Ico checkbox

    Feeding breast and formula

  • Ico checkbox

    Never breastfed

  • Ico checkbox

    Discontinued breastfeeding

  • Ico date

    Date:

  • Ico camera

    SOY REQUEST FOR CHILD: To substitute soy milk and tofu for cow’s milk and cheese, check or write ...

  • Ico checkbox

    Cow’s milk protein allergy

  • Ico checkbox

    Vegan

  • Ico checkbox

    Severe lactose intolerance

  • ...and More!

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