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.
Be 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
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. 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.
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: email@example.com