DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public Health F-01803 (02/2018) MATERNAL REFERRAL / COMMUNICATION WISCONSIN WIC PROGRAM To: Date: Demographic Information Name Date of Birth WIC Family ID Language Phone Cellphone Screening Data Date: Weight Height BMI Pre-pregnancy Weight Hemoglobin Referral / Communication Dietary Intake Hemoglobin results Weight Other Participant Consent By signing this form, I give my permission for WIC and the provider above to share information and coordinate nutrition services I know that I can cancel this consent at any time This consent is only valid through the current WIC program certification period If I do not sign this form, it will not put WIC eligibility or my WIC benefits at risk SIGNATURE Person Legally Authorized to Give Consent Date Signed – Printed Name Referral Completed By SIGNATURE Person Making Referral Date Signed – WIC Project Information and Plan (Return to WIC to ensure continuity of care) Provider’s Findings SIGNATURE Health Care Provider Date Signed – Additional comments Referral / Communication – This institution is an equal opportunity provider.
DEPARTMENT OF HEALTH SERVICES Division of Public Health F-01803 (02/2018) STATE OF WISCONSIN MATERNAL REFERRAL / COMMUNICATION WISCONSIN WIC PROGRAM To: Date: Demographic Information Name Date of Birth WIC Family ID Language Phone Cellphone Screening Data Date: Weight Height BMI Pre-pregnancy Weight Hemoglobin Referral / Communication Dietary Intake Hemoglobin results Weight Other Participant Consent By signing this form, I give my permission for WIC and the provider above to share information and coordinate nutrition services I know that I can cancel this consent at any time This consent is only valid through the current WIC program certification period If I do not sign this form, it will not put WIC eligibility or my WIC benefits at risk SIGNATURE – Person Legally Authorized to Give Consent Date Signed Printed Name Referral Completed By SIGNATURE – Person Making Referral Date Signed WIC Project Information Provider’s Findings and Plan (Return to WIC to ensure continuity of care) SIGNATURE – Health Care Provider Date Signed Additional comments – Referral / Communication This institution is an equal opportunity provider.