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.

 

Legend

= Required and must be completed

= Error with your information

Name



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

 

customerservice@genrx2u.com
844-436-7928

800-367-8939 TTY