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.
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.