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is This Client Eligible for Healthy Start 2018
Signature/Title of Health Professional Date PLEASE PLACE OFFICE STAMP BELOW Address Phone Number DH 3075 7/18 Replaces 1/16 edition which may be used. Florida Department of Health WIC Program This institution is an equal opportunity provider. Instructions for Completing the Florida WIC Program Medical Referral Form All shaded areas must be completed in order for the form to be processed. Check YES if the client has been screened and is eligible for Healthy Start. Is this client eligible for...Show details
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