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.



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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 to provide your credit card information.

Prescription Insurance Card

GenRx Pharmacy

17250 North Hartford Dr Suite 115, Scottsdale, AZ 85255

800-367-8939 TTY