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WIC Forms

The following forms are routinely used by the WIC Program.  Completion of forms prior to your WIC appointment may expedite your clinic visit.  Check with your clinic's staff to determine which form(s) you need to complete.  Some clinics may have the ability to accept forms electronically (fax, email, scan, etc.) others may require a printed copy of the form(s).

WIC Nutrition/Health Assessment

The WIC Nutrition/Health Assessment forms for pregnant women, postpartum women, infants, and children are part of a complete nutrition assessment and capture medical history information necessary for determining WIC eligibility.

English                           

Pregnant Woman

Post Partum Woman

Infant

Child

Notice of Proxy

The Notice of Proxy provides a mechanism to enable WIC participants to be represented by another person to continue program benefits when they are unable to come to the clinic during regular hours.

English

Notice of Proxy

Spanish

Aviso de Poder

Exception Request for Formula/Food

WIC provides supplemental infant formula. A WIC formula contract is required by the USDA and infants on standard milk-based or soy-based formula must be issued a contract formula. Oklahoma WIC currently has a contract with Gerber Good Start brand infant formulas. If your infant or child requires a medical formula, his or her healthcare provider may request that WIC make an exception by completing an Exception Request for Formula/Food. Formula exceptions are not guaranteed. Each one is considered on an individual basis and approval is dependent on funding. Formulas may not be issued solely for the purpose of enhancing nutrient intake or managing body weight and are not authorized for a non-specific formula or food intolerance.

Exception Request for Formula/Food

Oklahoma Unified WIC Approved Food Card

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