Patient Info Change Form

To keep your information current, please enter any changes below.


Personal Details

Shipping Address

PO Box addresses unfortunately, are not eligible for overnight shipping.

Contact Info

Healthcare Provider

Insurance Information

Your prescription is eligible for $0 refill program (meaning refills at no cost to you).

Check here if you do not want to participate in the auto-refill program.

$0 refill program is not available if prescriptions are paid in part or full by any state or federally funded programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD, or TriCare and where prohibited by law.
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Cash Patients, after submitting this form please call us at 844-436-7928 to provide your credit card information.

Prescription Insurance Card

GenRx Pharmacy

17250 North Hartford Dr Suite 115
Scottsdale, AZ 85255

New Patients

GenRx2u Card 2