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.

Customer Information Form

Name*
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Driver’s License Number
(Required by law in some states)
Phone
Email
Health Information
Please provide the following information to ensure quality service and care.
Allergies:
Conditions (e.g., Heart Disease, Diabetes, etc.):
Other Medications and/or Supplements:
Non-Safety Cap Option
Women’s International Pharmacy requires permission to have non-safety caps placed directly on all of your prescription vial(s). (You may change your mind about the use of such packaging at any time. Please contact the pharmacy should your packaging preference change.)
Please electronically sign below if you agree with the following statement:
Yes, I would like a non-safety cap placed on ALL of my prescription vials.
Name
First Middle Last
Date
Date Format: MM slash DD slash YYYY

You can also 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.

Customer Information Form

Customer Information Form

Health Information

Non-Safety Cap Option

You can also print out the Customer Information Form and return completed by fax or mail.

Mail or Fax All Forms and Photocopies To:

HIPPA: