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WIC Medical Formula Order, F-03043 (06/2022)

Medical Formula Order

This form is intended for WIC Directors or Project Nutritionists to order medical formula for participants to be shipped to local agency from the manufacturer. The following formulas are allowed for ordering:
  • Alfamino Infant
  • Alfamino Jr, unflavored
Formula must be locked up at the local agency where only WIC staff have access.

Ordering Steps
  1. Only WIC Directors or Project Nutritionists can place orders.
  2. Before ordering, ensure WIC staff will be available to accept the order.
  3. Place order request using this survey.
    • Allow at least two weeks for delivery. Depending on supply due to the current formula shortage, this may take longer.
    • Per Federal Regulations, only one month of formula may be ordered at a time per participant.
    • Refer to Reference Sheet #2 for formula-specific maximum amounts per month.
      • Use Elecare Infant amounts for Alfamino Infant
      • Use Elecare Jr amounts for Alfamino Jr
  4. The State WIC Office will place the order and send you the order confirmation. Confirm the order request and confirmation match. Report discrepancies within 24 hours to dhswicnutrition@dhs.wisconsin.gov.
  5. For questions about the ordering process, email dhswicnutrition@dhs.wisconsin.gov
  6. For other questions about formula, contact your regional consultant.
This question requires a valid email address.
4. Agency Name, Shipping Address, City, and Zip Code. *This question is required.