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WIC Forms

WIC - I love WICThe following forms are routinely used by the WIC Program.  Completion of forms prior to your WIC appointment may expedite your clinic visit.  Check with your clinic's staff to determine which form(s) you need to complete.  Some clinics may have the ability to accept forms electronically (fax, email, scan, etc.) others may require a printed copy of the form(s).

WIC Nutrition/Health Assessment

The WIC Nutrition/Health Assessment forms for pregnant women, postpartum women, infants, and children are part of a complete nutrition assessment and capture medical history information necessary for determining WIC eligibility.

English Spanish
Pregnant Woman Mujer Embarazada
Post Partum Woman  Para Mujueres Después del Parto
Infant Infante
Child Niño

 

 

 

 

 

Notice of Proxy

The Notice of Proxy provides a mechanism to enable WIC participants to be represented by another person to continue program benefits when they are unable to come to the clinic during regular hours.

English Spanish
Notice of Proxy Aviso de Poder

 

 

 
Exception Request for Formula/Food

WIC provides supplemental infant formula. A WIC formula contract is required by the USDA and infants on standard milk-based or soy-based formula must be issued a contract formula. Oklahoma WIC currently has a contract with Gerber Good Start brand infant formulas. If your infant or child requires a medical formula, his or her healthcare provider may request that WIC make an exception by completing an Exception Request for Formula/Food. Formula exceptions are not guaranteed. Each one is considered on an individual basis and approval is dependent on funding. Formulas may not be issued solely for the purpose of enhancing nutrient intake or managing body weight and are not authorized for a non-specific formula or food intolerance.

Exception Request for Formula/Food

  

 

Oklahoma Unified WIC Approved Food Card

English Spanish

 

Consent and Client Instructions for WIC Nutrition Education through Telehealth Services

Consent to Participate in WIC Nutrition Education Through Telehealth

Client Instructions for Joining Telehealth Through Teams - English

Client Instructions for Joining Telehealth Through Teams - Spanish

 

Public Charge Information:

WIC Public Charge Fact Sheet

 

Public Charge and Immigrant Participation in WIC - English

Public Charge and Immigrant Participation in WIC - Spanish

Public Charge and Immigrant Participation in WIC - Chinese

 

I Love WIC child

 


 WIC Participant Forms

 

The following forms are routinely used by the WIC Program.  Completion of forms prior to your WIC appointment may expedite your clinic visit.  Check with your clinic's staff to determine which form(s) you need to complete.  Some clinics may have the ability to accept forms electronically (fax, email, scan, etc.) others may require a printed copy of the form(s).

 

WIC Nutrition/Health Assessment
The WIC Nutrition/Health Assessment forms for pregnant women, postpartum women, infants, and children are part of a complete nutrition assessment and capture medical history information necessary for determining WIC eligibility.

English

Spanish

Pregnant Woman

Mujer Embarazada

Post Partum Woman  

Para Mujueres Después del Parto

Infant

Infante

Child

Niño

 

Notice of Proxy
The Notice of Proxy provides a mechanism to enable WIC participants to be represented by another person to continue program benefits when they are unable to come to the clinic during regular hours.

English

Spanish

Notice of Proxy

Aviso de Poder

 

Exception Request for Formula/Food
WIC provides supplemental infant formula. A WIC formula contract is required by the USDA and infants on standard milk-based or soy-based formula must be issued a contract formula. Oklahoma WIC currently has a contract with Gerber Good Start brand infant formulas. If your infant or child requires a medical formula, his or her healthcare provider may request that WIC make an exception by completing an Exception Request for Formula/Food. Formula exceptions are not guaranteed. Each one is considered on an individual basis and approval is dependent on funding. Formulas may not be issued solely for the purpose of enhancing nutrient intake or managing body weight and are not authorized for a non-specific formula or food intolerance.

Exception Request for Formula/Food

 

 

 

 

 

 

 

 

 

 

 

 

This institution is an equal opportunity provider.

 

 
 
Infante

English

Spanish

 

 

 

 

 

 

 

This institution is an equal opportunity provider.

 

 

 

 

 

 

 

 

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