To request an appoinment for WIC,
please complete the following form we will contact you as quickly as possible.

Appointment Information
I'd like my first appointment in...
I would like to make an appointment for a ........

Pregnant Women
Newborn Baby
Child (up to age 5)
Breastfeeding Women

Patient Information
Patient's First Name
Patients Last Name
Date of Birth

Contact Information
Preferred appointment day of the week?
Preferred Appointment Time
How can we reach you best by phone? ( ) -
Best time to call?

Morning
Afternoon
Evening
OK to leave a message?

Yes
No
Email Address
Additional Comments


Please note that when requesting an appointment, this form does not guarantee an appointment time.

A member of our staff will contact you by phone for
appointment conformation.

If you require immediate or further assistance please contact us directly by calling:

Jefferson County
(315)782.9222

Franklin County
518.483.4262

Lewis County
(315)376.6427

St Lawrence County
(315)386.8128

238 Arsenal St.
Watertown, NY 13601
P. (315)782-9450  F. (315)782-2643


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North Country Children's Clinic, Inc. • 238 Arsenal St. •  Watertown, NY 13601
P. (315)782-9450 F. (315)782-2643