WIC Consent to Contact

WIC Consent to Contact
Name*

First NameLast Name
Date of Birth*

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Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

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CityState / Province

Postal / Zip Code
Estimated Due Date

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Date
Estimated Discharge Date

MonthDayYear
To be completed by Good Samaritan employees when applicable
Preferred Communication*

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Referral Status*

Self ReferralAgency Referral
Referring Office Name*
Referring Office Location*

Street Address

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CityState / Province

Postal / Zip Code
Referring Office Phone*
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Referring Office Fax*
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Programs are available in your community to promote strong healthy families by providing support to parents who are expecting, have a newborn, or have children under the age of 5. WIC provides supplemental nutrition assistance as well as health screenings, nutrition education, breastfeeding support, and community referrals.

By signing this consent, you are taking the first step to get this valuable support. A representative from the WIC clinic will be in touch with you to tell you more about their program. We have asked this program to notify us if they were able to provide assistance. Signing this does not commit you to participate in any program.
By clicking "I agree" below, you are acknowledging that this is your virtual signature.*

I agree
Today's Date*

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