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Get 703b Miwic Infant Child Med Doc-no Headerdoc - Dhd2

Address: WIC Contact Person: Phone: Fax: Prescription: Completion of this form is federally required to ensure that the WIC client under your care has a qualifying condition (medical condition/diagnosis) that requires the use of a WIC formula, medical food and/or changes to their supplemental food package. A health care provider's prescription will not be accepted as a repl.

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