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A and D for all WIC participants. To request exempt formula and prescribe supplemental foods, complete section B. To request soy beverage or tofu for milk protein allergy, complete section C. A. PATIENT INFORMATION (Further instructions on reverse.) Patient s Name: Date of Birth: B. EXEMPT FORMULA AND WIC SUPPLEMENTAL FOODS Formula Requested: Length of Use: Prescribed Amount: ounces/day 1 month 6 months 3 months 12 months months Speci.

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