Patient History 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, please visit 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.

Mail or fax all forms and photocopies to:

PO Box 6468
Madison, WI 53716-0468
Fax: (800) 279-8011

Be assured that this information will remain confidential.

Customer Information

Health Information

e.g., Heart Disease, Diabetes, etc.