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L condition that requires the use of specialty formula and that conventional foods are precluded, restricted, or inadequate to meet their special nutritional needs. Instructions: Complete sections A and D for all patients. To approve specialty formula and supplemental foods, also complete section B. To approve soy beverage, tofu or additional cheese, also complete section C. Fax form to WIC clinic or have WIC participant return form to clinic. WIC clinic: WIC fax #: Attention: A. Patient infor.

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