Forms

Credit Card
Authorization Form

This form authorizes our pharmacy to charge your credit card for services and fees related to an associated patient account.

Offline Patient
Information Form

For parents or guardians choosing to register offline.

Physicians
Instruction Letter

For parents, guardians, or patients to provide a physician with instructions for writing prescriptions consistent with New Jersey Pharmacy regulations.

Address For Mailing Forms And Prescriptions

PersonalRX
20 Murray Hill Parkway, Suite 210
East Rutherford, NJ 07073

Phone
877.242.4369

Fax
201.334.0700

e-Script Information For Prescribing Physicians

NAPB # 3196563

Pharmacy Name
Personalrx / DGN Pharmacy Inc.

Address
20 Murray Hill Parkway, Suite 210

East Rutherford, NJ 07073

Phone
877.242.4369

Your Pharmacy. Delivered.

You are moments away from a better, simpler pharmacy.

Or call us now and we'll help you decide if PersonalRX is right for you. 877.230.6030

20 Murray Hill Parkway,
Suite 210,
East Rutherford, NJ
07073

support@personalrx.com
877.230.6030

Mail Service Pharmacy 01/01/2026

LegitScript approved

© 2023 PersonalRX