WIC Appointment & Health History Forms

If you have any questions about these forms, your WIC appointment, or WIC in general, please call 419-774-4560 in Mansfield or 419-289-3359 in Ashland.  WIC is happy to serve you!

Hey Mom and Dad!

To make it easier for WIC Services in Richland and Ashland Counties, you can now print out copies of the necessary forms at home! Completing the forms at home will save you time when you come in for your WIC appointment.

These forms need to be completed for WIC Certification and Recertification appointments. Complete one WIC Application per family and a Health History form for each woman, infant and child applying for WIC services.

WIC Program Application Form

WIC Health History for Breastfeeding Women and Postpartum Women

WIC Health History for Pregnant Women

WIC Health History for Infants

WIC Health History for Children 1-5 Years

Questions or Comments

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