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Appendix 2.016C Effective May 2014 D.C. WIC Medical Documentation & Referral Form for WOMEN, INFANTS & CHILDREN
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Document Date: 2014-07-10 10:53:11

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File Size: 281,12 KB

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Company

WIC / /

Facility

FAX TO THE WIC CLINIC / /

IndustryTerm

formula/medical food / medical food / food intolerance / /

MedicalCondition

Premature birth / Food Allergy / Milk Allergy / GERD / Malabsorption Syndrome / lactose intolerance / Immune system disorders / Metabolic disorders / constipation / Gastrointestinal disorders / /

MedicalTreatment

Vegan diet / /

Organization

Medical Office / /

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Position

CPA / Nurse Midwife / /

SocialTag