Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the Ohio WIC Formula Prescription Form and open it for editing.
2. Begin by entering the patient’s name and date of birth clearly in the designated fields.
3. Fill out the caregiver’s name and phone number, ensuring accuracy for effective communication.
4. If applicable, indicate the number of weeks the patient was born early, providing crucial medical details.
5. Specify the amount of formula needed per day by completing the relevant field with accurate measurements.
6. Select the intended length of use by checking the appropriate box for one to six months.
7. Provide the medical diagnosis in the specified field, ensuring it supports the necessity of the requested formula.
8. Choose from the prescribed formulas listed for infants and children or adults, making sure to select the correct option.
9. Indicate any contraindications or restrictions regarding WIC foods that may be required for the patient.
10. Complete the healthcare provider section by entering their name, phone number, and obtaining their signature and date.
11. After reviewing all entries for accuracy, save your changes, and choose to download, print, or share the completed form as needed.

Start filling out your forms online today for the Ohio WIC Formula Prescription.