Customer Information Form - Womens International Pharmacy

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Customer Information Form
Women's International Pharmacy recognizes the importance of keeping your
customer information up to date so that our staff can provide you the best quality
service. Please complete this form and return it in the envelope provided, at your
earliest convenience. Be assured that this information will remain confidential.
Name: _________________________________________________________
First
M.I.
Last
Street Address: __________________________________________________
City: __________________________________________________________
State: ____________________Zip Code: ______________________________
Date of Birth: _________________________ Sex M / F_________________
(Circle One)
Social Security Number: ____________________________________
or
Driver’s License Number: _________________________________________
(Required by law in some states.)
Phone Number (Home): ________________ (Business): _________________
Email Address: _______________________ (Cell): _____________________
Health Information
Please fill in the pertinent information regarding your current health condition
to ensure quality service.
Allergies: _______________________________________________________
Conditions (i.e., Heart Disease, Diabetes, etc.): __________________________
_______________________________________________________________
Other Medications and/or Supplements: ________________________________
__________________________________________________________
(Over)
Telephone: (800) 279-5708 ▪ FAX: (800) 279-8011
E-mail: ▪ Website:

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