Skip to main content
Your browser does not support iFrames
WIC - Approved Formula Request Form
This form is intended to make finding formula as efficient as possible. After completing the form, click the submit button and it will automatically be sent to the Vendor Management Agency (VMA), Public Health Solutions, at
vma@healthsolutions.org
.
This form is the preferred method for requesting VMA assistance, but this information may be emailed or shared by phone with the VMA.
If the VMA can locate the formula, the participant will be contacted via email or phone based on their preference.
If the VMA cannot locate the formula, the Local Agency will be contacted for the next steps at which point they may request a drop shipment if necessary.
Are you a WIC Participant or WIC Local Agency Staff?
Are you a WIC Participant or WIC Local Agency Staff?
- Select -
WIC Participant
WIC Local Agency Staff
Other…
Enter other…
Participant’s contact information:
Name
Participant’s Email
ZIP Code
Phone
Local Agency Staff contact information:
Name
Email
Name of the formula requested
Is the formula requested:
- None -
Powder
Concentrate
Ready to use (RTU)
How many unopened cans does the participant currently have?
How many cans are available in the participant’s current benefits cycle?
When do the participant’s current benefits expire?
What is the participant’s preferred method of contact?
- None -
Email
Phone
Where is it most convenient for the participant to shop? Please include general locations and/or specific stores.
What is the ZIP code of the most convenient place for the participant to shop?
What form of travel does the participant utilize to purchase formula from WIC approved vendors? Please check all that apply.
Walking
Public Transportation
Owned/Borrowed Vehicle
Other
How far can the participant travel to purchase formula (miles)?
- None -
<1
1-5
6-10
11-15
16-20
21+
What stores have the participant called or visited to ask about this formula?
What was the participant told by the store staff when asking about the formula?
Is there any additional information you feel is helpful for Public Health Solutions to be able to service this request?
If a drop shipment needs to be facilitated and is available, what is the Local Agency address and contact info?
Name of Local Agency staff person
Address
Address
City
ZIP Code
CAPTCHA
Submit