WIC Forms

When you participate in WIC, staff will ask you for some information. Some forms are required to participate. WIC staff will let you know if you need to fill out any of these forms.

Do you want to do your WIC appointment from home instead of coming into Adelante Healthcare?
Please contact us at 1.877.809.5092 for more information.

Adelante WIC Patient Forms

WIC Rights and Responsibilities

WIC Rights and Responsibilities Spanish

Voter Registration

Pump Loan Agreement

Statement of Documentation

Statement of Documentation Spanish

Change of Authorized Rep

Change of Authorized Rep Spanish

Language Access Waiver

Language Access Waiver Spanish

Notice of Ineligibility

Notice of Ineligibility Spanish

Proxy Certification

Proxy Certification Spanish

AZ Referral & physical presence Exemption Form

 

Note:  All Forms require the free version of Adobe Reader for viewing and printing. Download a free copy of Adobe Reader here.

Click here to view forms in more languages.

 

 

WIC COVID-19 Updates

COVID-19 Update: WIC is open for business. Adelante Healthcare WIC is currently doing over the phone appointments until January 20, 2021.

WIC @ Adelante Locations

Adelante Buckeye
Open Mon-Fri 8am to 6pm
Closed for lunch 12pm-1pm

Adelante Healthcare Central Phoenix
Virtual and remote services available.

Adelante Gila Bend
Open Wed 8am to 4:30pm
Closed for lunch 12pm-12:30pm

Adelante Goodyear
Open Mon – Fri 8am to 5pm
Walk-in Hours 8am-11am & 1pm-4pm
Closed for lunch 12pm-1pm

Adelante Mesa
Open Mon – Fri 8am to 5pm
Closed for lunch 12pm-1pm

Adelante Peoria
Open Mon, Tues, Thurs 8am to 5pm (By Appointment)
Friday (Walk-Ins) 8am to 5pm
Closed for lunch 12PM to 1PM

Adelante West Phx
Open Mon-Fri 8am to 6pm
Sat 8am to 5pm (By Appointment)
Closed for lunch 12PM to 1PM

Adelante Surprise
Open M-F 8am to 6pm
Appointments Tues, Wed, Thurs and 2nd Sat of the month.

Adelante Wickenburg
Open Tues & Thurs 8am to 5pm
Closed for lunch 12-1pm

Stand-Alone WIC @ Adelante Locations

Luke Air Force Base WIC
7282 N. 137 Ave., Bldg. 1140
Glendale, AZ 85142
Ph: 1-877-809-5092
Fx: 623-583-3007

Military Pass Required
Open Mon & Wed 8am to 5pm
Closed for lunch 12-1pm

West Valley WIC
328 W. Western Ave.
Avondale, AZ 85323
Ph: 1-877-809-5092
Fx: 623-333-0271

Open Mon-Th 8am to 5:30pm | Fri 9am to 5pm
Closed for lunch 12pm-1pm
Please call to schedule your appointment

Peoria (South) Mobile WIC
8335 W. Jefferson St.
Peoria, AZ 85345
Ph: 623-236-4622

Open Tues & Wed 8am to 5pm by appointment
Closed for lunch 12-1pm
Please call to schedule your appointment

WIC Patient Forms

WIC Forms

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