Patient Info Change Form

To assist us in completing your new prescription, enter your information below. Be sure to have your insurance card and healthcare provider’s contact information before you begin. If you have any questions or would like to better understand our process, please feel free to contact customer service at 844-436-7928.



= Required and must be completed

= Error with your information


Personal Details

Shipping Address

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

Contact Information

Doctor's Information

Insurance Information

Cash Patients, after submitting this form please call us at 844-436-7928 (Option 2) to provide your credit card information.

Prescription Insurance Card

Prescription Transfer

If required by your prescription insurance provider, may GenRx have your permission to transfer your prescription to a pharmacy that accepts both your insurance and the PruGen Solutions $0 Co-Pay Program?Required

More Information

In order to receive your eligible prescription for $0, you must select "Yes" to transfer.