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Online Customer Information Form

For customers only, please fill out the following Customer Information Form after you have received your first prescription or wish to update your information with us. After submitting the Customer Information Form, you will be directed to the Notice of Privacy Practices page. To protect the privacy of your individual health information, please review and submit the HIPAA form.

Non - Safety Cap Option

To have a non-safety cap placed directly on all of your prescription vial(s), Women's International Pharmacy is required to receive a signature for permission. To take advantage of this service on ALL prescription vials, print out the Customer Information Form*. Complete the form and return by fax or mail.

* Requires Adobe Acrobat Reader

Mail or fax all forms and photocopies to:

Women's International Pharmacy
PO Box 6468
Madison, WI 53716-0468
Fax: (800) 279-8011

Secure ServerBe assured that this information will remain confidential.

Customer Information



Health Information


Automatic Mail Service

At your request, we can send your refills automatically. Please contact a pharmacy technician for details.
Call toll free: 1-800-279-5708, (press option 3).


The Prescription Information Sheet that comes with each prescription can be used to file claims with your insurance company if your medication is covered. Please note, your insurance company will pay you directly. Please note you are required to pay in full at the time of order.


We accept payment in a variety of forms. Options include: credit card, check, cash, or money order. You may also request to have your credit card number kept on file for future payments. To take advantage of this service, print out the Customer Information Form*. Complete the form and return by fax or mail.