NEW JERSEY WIC HEALTH CARE REFERRAL

FOR

INFANT (Under 1 Year)	CHILD (1 to 5 Years)

(Please attach updated Immunization Record.)
Name of Child

Birthdate of Child

/ /

Women, infants and children MUST be present at every WIC certification appointment.

Bring:

∙Proof of your family's income

∙Proof of where you live

∙Proof of ID for every person

∙Health care referral form filled out

∙Immunization records of infant/child

CALL for an appointment with WIC office checked:

(Healthcare provider:

Check WIC office for patient.)

Burlington County

609-267-4304

Children’s Home Society

of NJ

609-498-7755

East Orange

973-395-8960 (8963)

Gloucester County

856-218-4116

Jersey City

201-547-6842

Newark

973-733-7628

North Hudson

201-866-4700

NORWESCAP

908-454-1210

Ocean County

732-341-9700 X 7520

Passaic

973-365-5620

Plainfield

908-753-3397

Rutgers

973-972-3416

St. Joseph

973-754-4575/4730

TriCounty/Gateway CAP

Main Office:

856-451-5600

Atlantic Office:

609‑246‑7767

Camden Office:

856‑225‑5050

Trinitas

908-994-5141

VNA

732-471-9301

OR

STATEWIDE

1-800-328-3838 (24 Hrs.)
Name of Parent/Guardian

Telephone Number

Address

ANTHROPOMETRIC AND LABORATORY DATA

Current height and weight measurements are needed for all infants and children.

Height and weight measurements must be taken <30 days prior to WIC appointment.

At least ONE blood test of Hemoglobin, Hematocrit or Erythrocyte Protoporphyrin (EP) is needed to determine nutritional risk of infants and children OVER 9 MONTHS of age.

The blood test must be taken <90 days prior to WIC appointment.
Blood Test Date

/ /	Hemoglobin

gm/dl	Hematocrit

%	EP

(g/dl	Screened for Lead?

Yes

No	(g/dl
Date of Ht./Wt. Measurement

/ /	Height or Length

inches	Weight

lbs. ozs.
COMPLETE THIS SECTION FOR FIRST TIME WIC APPLICANTS ONLY
Birth Weight

lbs. ozs.	Birth Length

inches	Premature?

Yes No	If Yes, Gestational Age at Birth:

weeks
MEDICAL HISTORY
Check all of the following which apply and give a brief explanation:

Metabolic disorder, congenital anomalies or other medical problem

Hx of severe diarrhea, steatorrhea, vomiting, malabsorption (3 times during past year or 1 time in past 6 months requiring hospitalization)

Major surgery (within past 6 months)

Excessive dental carries/baby bottle tooth decay

Maternal prenatal conditions (e.g., prenatal anemia, multiple birth, inadequate prenatal weight gain)

Social or environmental condition which may compromise adequacy of diet

Vitamin/mineral supplement or medicine prescription

Other pertinent health or medical data

Explanation

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

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_________________________________

_________________________________
AUTHORIZATION RELEASE

I, the undersigned, give permission to my provider to give the WIC Program any required medical information.
Signature of Parent/Guardian
Insurance Carrier and Member ID Number

Signature of Physician or Health Professional	Date
Name and Address of Physician or Clinic (Print or Stamp)

Telephone Number:
WIC-42

APR 16	This institution is an equal opportunity provider.

WIC-42, WIC Health Care Referral, Infants and Children

wic-42, wic Health Care Referral, Infants and Children, WIC, WIC Services

EWhite

2016-03-31

NJDHSS