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Get Mt Wic Infant Formula Request Form 2021-2024

Date: B. Length of Time Requested (circle one or fill in end date): Until end of certification Until first birthday Months of Age: Other Date: C. Medical Formulas/Nutritional Products (Food Package 3): Prescribed Amount: Maximum Allowable OR per day Infant Formula Brief Product Description Diagnosis* Enfamil Enfacare NeuroPro Neosure 22 calories per ounce; higher concentrations of proteins, vitamins and minerals (calc.

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