Detroit Health Department WIC Appointment and Inquiry Form

Detroit Health Department

WIC Appointment and Inquiry Form

Form Date Field

Clinic Location*

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Inquiry Type*

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First Name*

Last Name*

Address*

City*

State*

Zip Code*

Primary Phone Number*

Email Address

Type of WIC Client*

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Please tell us how we can assist you

How did you hear about us?*

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Referring Community Program/Organization

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