Refer WIC-eligible patients to the San Bernardino County WIC program using the forms below. Information provided will be used by the WIC program to review your patient's health status and provide nutrition counseling. When completing each referral form, remember to:
- Include the patient's labs (hemoglobin and hematocrit, lead levels, height and weight).
- Make sure the form is completely filled out, signed, and dated before giving it to parents or caretakers.
- Contact WIC if you need the latest referral forms.
WIC Referral for Pregnant Women
Refer pregnant patients to San Bernardino County WIC.
Intended Audience:
Health care providers, clinic staff.
Dimensions: 8.5” x 5.5” form
WIC Referral for Postpartum/Breastfeeding Women
Refer postpartum patients to San Bernardino County WIC.
Intended Audience:
Health care providers, clinic staff.
Dimensions: 8.5” x 5.5” form
WIC Pediatric Referral
Refer infants and children to San Bernardino County WIC.
Intended Audience:
Health care providers, clinic staff.
Dimensions: 8.5” x 11” form