Classic Pharmacy Delivery - Health & Wellness

Please submit this form and a copy of your insurance card for delivery of your prescription from Classic Pharmacy to Wagner College. A new prescription may need to be obtained from the Wagner College Center for Health and Wellness.

Classic Pharmacy

This form will provide Wagner College and Classic Pharmacy with your Insurance information in order to fill your prescription.

Name*
First Last
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Deliver Prescription to Wagner College Campus*
Yes or No
Email*
Phone*
Name of Insurance Company*
Supply Insurance Company Prescription Card Information.
Insurance ID #*
Prescription Card BIN #*
Every Prescription Card has a BIN #. If there is not a BIN # then it is probably not your Prescription Card.
PCN #
Rx Group #
I understand that I must call Classic Pharmacy with my credit card information before my prescription order is processed.*
Classic Pharmacy: 718-727-0022
- Yes, I agree to call Classic Pharmacy.
Signature
Signature required upon delivery
Comments
This field is for validation purposes and should be left unchanged.

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