Customer Information Form - Womens International Pharmacy Page 2
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1
2Non-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.
Yes, I would like a non-safety cap.
_____________________________________
_________________________
(Your signature)
(Date)
Women’s International Pharmacy Offers Additional Services:
Automatic Mail Service
At your request, we can send your refills automatically. Please contact a
pharmacy technician for more details.
On-Line Services –
Prescription Refills
Supplements
Ask a Pharmacist
AutoPay
Payment is required at the time of the order. We offer a convenient AutoPay
Plan. Just complete the information below and we will retain this information on
your file.
When you or your practitioner requests an order, your Debit/Credit Card will
automatically be charged.
□ MasterCard
□ Visa
□ American Express
□ Discover
Number:
Exp. Date:
_________________________________________
__________
Signature:
_____________________________________________________________
Women’s International Pharmacy
Telephone: (800) 279-5708 ▪ FAX: (800) 279-8011
E-mail: ▪ Website:
______________________________________________________________________________________________________________________
th
2 Marsh Court
12012 N. 111
Avenue
Madison, WI 53718
Youngtown, AZ 85363
Phone (608) 221-7800
Phone (623) 214-7700
Fax (608) 221-7819
Fax (623) 214-7708
Rev. 07/2011
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