South Carolina WIC uses this referral to collect accurate, current measurements and medical history from a patient's primary care physician or pediatrician. Patients often bring it to be filled in before their next WIC appointment, and offices also use it to refer a new client. It covers women, infants and children under 24 months, and children 2 to 5, with a checklist of diagnoses and concerns.
A health care provider completes and signs it, using a separate form for each patient. Only the patient's name and date of birth are required in section A; the provider fills the matching block in section B, checks concerns in section C and signs section D.
Download the current version from the source each time; forms change without notice.
Medical Referral Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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A health care provider completes and signs it. The instructions describe it as a form for primary care physicians and pediatricians to share medical history and measurements. The medical office information can be handwritten or stamped, and each patient needs a separate form.
A hemoglobin or hematocrit is required for pregnant women (current pregnancy) and postpartum or breastfeeding women (postpartum period). For infants it is recommended once between 6 and 12 months, and children need it on a schedule based on whether the last result was normal. A venous lead value is optional.
The instructions say pregnant women are eligible through the pregnancy and up to 6 weeks postpartum, postpartum women up to 6 months after delivery or end of pregnancy, breastfeeding women up to one year after delivery, and children until their fifth birthday.