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.
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 | Spanish |
| Notice of Proxy |
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. Effective October 1, 2024, Oklahoma WIC’s formula contract will be with Similac 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.
WIC Information Form
The WIC Information Form is used to provide health and medical information to the WIC Program as needed. The form should be completed and signed by the healthcare professional and returned to the clinic.
Consent and Client Instructions for WIC Nutrition Education through Telehealth Services
WIC Participant Breast Pump Referral
Contact Information
Mailing Address:
Oklahoma State Department of Health
WIC Service
123 Robert S. Kerr Ave., Suite 1702
Oklahoma City, OK 73102-6406
Physical Address:
Oklahoma State Department of Health
123 Robert S. Kerr Ave.
Oklahoma City, OK
Phone: (405) 426-8500
Toll Free: (888) 655-2942
Fax: (405) 900-7576
This institution is an equal opportunity provider.
