Provider Referral for Vermont WIC

Vermont WIC provides nutrition counseling, breastfeeding support and healthy foods free for Vermont families who qualify. With patient permission, complete this online referral and Vermont WIC will reach out to determine eligibility and set up an enrollment appointment.

1. Who is the referral for?

Name *This question is required.

First name
Last name

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

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The above named person is: *This question is required.

If available, please provide measurements from within the past 60 days.

Length/Height (in inches)
Weight (in pounds)

Date above measurements were taken: This question requires a valid date format of MM/DD/YYYY.

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If available, please provide anemia screening results from within the past 90 days.

Hemoglobin, or
Hematocrit

Date above anemia screening was completed: This question requires a valid date format of MM/DD/YYYY.

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2. Are there additional family members who may be eligible for WIC? If so, please list them here:

Space Cell	Name	Date of Birth
Additional family member:	Additional family member:: Name	Additional family member:: Date of Birth
Additional family member:	Additional family member:: Name	Additional family member:: Date of Birth
Additional family member:	Additional family member:: Name	Additional family member:: Date of Birth

3. Family Contact Information

First Name *This question is required.

Last Name *This question is required.

Street Address *This question is required.

Apt

City *This question is required.

Zip *This question is required.

Email Address

Primary Phone Number *This question is required.

Secondary Phone Number

4. What is the family's preferred spoken language?

5. Does the family need an interpreter?

6. Additional information:

7. Please select the option that describes your organization.

8. Medical Provider: Please complete the following information *This question is required.

Practice Name:
Medical Provider Name:
Practice Phone Number:

8. Children's Integrated Services Provider: Please complete the following information *This question is required.

Organization Name:
Your Name:
Your Phone Number:

8. Other Community Partner Organization: Please complete the following information *This question is required.

Organization Name:
Your Name:
Your Phone Number:

8. By checking Agree below, you are confirming the above-mentioned patient(s) agrees to have WIC contact them. The Vermont Department of Health WIC Program will share this information with the local WIC agency in their area. Please see the Vermont privacy policy for further information on the electronic transmission of information to the WIC program. This institution is an equal opportunity provider.

To continue, check 'Agree' below and then click the Submit button, or the arrow if on a mobile device. *This question is required.

Agree