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Get Wic Form Florida

Date PLEASE PLACE OFFICE STAMP BELOW: Address: Phone Number: ***Parent or Guardian: Please bring a copy of your baby s/child s shot record to the WIC office.*** DH 3075, 8/09 Stock Number: 5744-000-3075-5 (Replaces 12/03 edition which may be used.) WIC is an equal opportunity provider. Instructions for Completing the Florida WIC Program Medical Referral Form All shaded areas must be completed in order for the form to be processed. 1. Check ( ) YES.

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