Women's International Pharmacy | Custom Compounded Bioidentical Hormone Prescriptions for Men and Women

   Questions? Call Toll-Free 800. 279. 5708

 
   
  HIPAA Form  
  Customer Information
Form
 
   
  Patient Info Request  
  Practitioner Referral Request  
  Prescription Procedures  
  Medicine Disposal  
   
  Practitioner Info Request  
  Quality Assurance  
  New Rx Instructions  
  Rx Authorization Instructions  
  Practitioner Resources  
  Conference Calendar  
     
   
 
 

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.

Secure ServerBe assured that this information will remain confidential.

 

Non - Safety Cap Option

To have a non-safety cap placed directly on your prescription vial(s), Women's International Pharmacy is required to receive a signature for permission. To take advantage of this service, 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

Customer Information

Female

Male


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).

Insurance

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

Payments

You may 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.

 

 

Women’s International Pharmacy, Inc.
Toll Free Phone: 800. 279. 5708 ~ Toll Free Fax: 800. 279. 8011 ~ Email: info@womensinternational.com