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.


To better serve our patients, your prescription may be filled by one of our partner pharmacies. 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 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.
Get verbiage from Crane.
Cash Patients, after submitting this form please call us at 844-436-7928 to provide your credit card information.

Prescription Insurance Card

Network Transfers

GenRx Pharmacy

17250 North Hartford Dr Suite 115
Scottsdale, AZ 85255

New Patients

GenRx2u Card 2