Skip survey header

Provider Referral for Vermont WIC

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.
This question requires a valid date format of MM/DD/YYYY.
calendar
The above named person is: *This question is required.
If available, please provide measurements from within the past 60 days.
This question requires a valid date format of MM/DD/YYYY.
calendar
If available, please provide anemia screening results from within the past 90 days.
This question requires a valid date format of MM/DD/YYYY.
calendar
2. Are there additional family members who may be eligible for WIC? If so, please list them here:
Space Cell NameDate of Birth
Additional family member:
Additional family member:
Additional family member:
3. Family Contact Information
5. Medical Provider: Please complete the following information *This question is required.