Information Request

Information Request Form

* Required Fields

*First Name:

*Last Name:

Are you a Healthcare Professional? If so, enter your degree: 

Apartment No.:

*Street Address/P.O. Box:

*City:

*State:

*Zip Code:

*Country:

*Email:

Home Phone: (please include area code)

Business Phone: (please include area code)

I would like information on: Female Hormone Therapies    Male Hormone Therapies

Yeast Information

Women's International Pharmacy offers a list of practitioners who have
prescribed through our pharmacy. Would you like this referral
sent along with your information packet request? Yes

If interested in the referral list, please enter below
any additional cities you would travel to.

*How Did You Hear About Us? Book Colleague Conference Email Family Friend Patient Practitioner Website

Women’s International Pharmacy is pleased to provide various information pieces on
bioidentical hormone use. Providing these resources does not warrant that this information
should be substituted for medical advice provided by your healthcare practitioner. All
benefits and risks should be discussed within the context of consultation with your healthcare
practitioner. Women’s International Pharmacy also maintains a list of practitioners who have
used our services. Please take note that the names Women’s International Pharmacy provides
does not imply endorsement by Women’s International Pharmacy nor a liability for the success
of the patient-practitioner relationship; nor a liability for the fitness of hormone protocols
chosen by these practitioners.

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