* First Name:

* Last Name:

*Street Address:
Apt. Number:

* City:
* State: * Zip Code:

* Country:

* E-mail Address:
 

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How did you hear about us?

Friend	Family	Website	Book	E-mail
Conference	Practitioner	Colleague	Patient
Other  (please provide explanation)

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* Gender:

Female  Male

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*Are you currently a customer of Women's International Pharmacy?

 Yes  No

 

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Have you received our information packet regarding bioidentical hormone therapies?

 Yes  No

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Are you having symptoms of: PMS        (PRE-POST)MENOPAUSE POSTPARTUM       INFERTILITY OTHER (please provide explanation)

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Are you currently taking medication/supplements for your symptoms?

 Yes  No

If so, what are you taking?


 

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Please use space below to briefly describe your questions or concerns.


 

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Within our *business hours when is a good time to reach you by telephone?

* Telephone:         * Time:  


*Our business hours are 9:00 am - 5:30 pm (Central Standard Time).


Depending upon the nature of your question, our pharmacists may need to respond to you by a telephone call - to better serve you. Responses by email can take up to 3 business days.