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Click ‘Get Form’ to open the pediatric referral form in the editor.
Begin with SECTION I. Fill in the patient’s name, current height, weight, and BMI. Ensure these measurements are within the last 60 days for accuracy.
Complete the hemoglobin or hematocrit test results and lead test information as required. Indicate if immunizations are up-to-date by selecting 'Yes', 'No', or 'Not available'.
Provide the patient's date of birth and measurement date, along with birth weight and length details.
Assess breastfeeding status by selecting one of the options provided. If applicable, check any conditions for soy requests.
In SECTION II, complete all boxes when a therapeutic formula is prescribed. Include diagnosis details and specify WIC food restrictions.
Fill in the formula or medical food details, duration, amount per day, and check if it’s a new prescription or refill.
Lastly, provide health coverage information and any actions taken regarding insurance or referrals.

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ohsu pediatric referral form

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