Customer Information Form

From new addresses to personal health updates, keeping your account information current ensures you receive the best service from Women’s International Pharmacy.

Be assured that this information will remain confidential.

Health Information or Non-Safety Cap Option

If you need to update your health information or to have a non-safety cap placed directly on all of your prescription vials, Women’s International Pharmacy is required to receive a completed form returned by fax or mail. To take advantage of our non-safety cap option on ALL prescription vials we require a signature for permission.  Print out the Customer Information Form and return completed by fax or mail.

Mail or Fax All Forms and Photocopies To:

2 Marsh Court
Madison, WI 53718

Fax: (800) 279-8011

HIPPA:

• After submitting the Customer Information Form, please visit our HIPAA and Privacy page to read Women’s International Pharmacy’s Notice of Privacy Practices.
• To protect the privacy of your individual health information, please review and submit the HIPAA form.