Ohio Women, Infants, and Children (WIC) Prescribed Formula and Food Request

This form is provided by the Ohio Women, Infants, and Children Authorized Foods and Formula List Committee. This form is intended to be used by pediatricians to request prescribed food and formulas for their patients. Any questions regarding this form should be directed towards the Ohio WIC Program at the Ohio Department of Health.

Ohio Women, Infants, and Children (WIC) Prescribed Formula and Food Request Form