Pharmaceutical Product Usage Form

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.

Contact Us

Milwaukee
La Crosse
Marshfield

Please enter your hospital location name.

Product Information

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

* Fields are required.