Location out of bounds

Pharmaceutical Product Usage Form

Complete this online form as an alternative to faxing a Pharmaceutical Product Usage Form.

Contact Us

Pharmacy Department

Please contact us by email or phone if you have any questions.
Email Milwaukee
414-937-6160
La Crosse
608-782-4477
Marshfield
715-387-4990

Complete the Product Usage Form Below To Send Us Your Information


Customers enrolled in Versiti’s Pharmaceutical Product Consignment Program are required to notify our pharmacy department once products have been used from their consignment inventory.

Using the form below, please enter the required customer/contact and product information. Upon submission, this information is relayed to our pharmacy team for processing and invoicing.

If applicable, please submit non340B and 340B product usages on separate form submissions. If you have a 340B account and are submitting 340B product usage, in the Location Name field after typing your hospital name add “340B”.

If you have any questions on using the online form submission, please contact our pharmacy department.

Please enter your hospital location name.

* Location Name:


* First Name:

* Last Name:

* Email:

Phone Number


Product Information




If you are sending information on additional products click the radial button below.


* Please enter required code below.

Enter security code:
 Security code


* Fields are required.

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