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NEW YORK STATE DEPARTMENT OF HEALTH DIVISION OF NUTRITION For WIC Use Date Mailed/ Given Date Rec d Appt Date WIC ID WIC MEDICAL REFERRAL FORM FOR INFANTS and CHILDREN Child s Last Name Print Child s First Name Parent/Caretaker s Name Street Apt No City Zip On WIC Before Yes Sex M F Phone Child s DOB // Language s Spoken I authorize Health Care Provider to release the information below to the WIC Program and I authorize the WIC P....
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