Classic Pharmacy

Please submit this form so your prescription can be filled by Classic Pharmacy. A new prescription may need to be obtained from the Wagner College Center for Health and Wellness office. IMPORTANT: You must send a copy of your medical insurance card to classicrx@gmail.com and studenthealthservice@wagner.edu

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

Name*
First Last
Home Address (not Wagner address)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
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 and send them a copy of my current insurance card before my prescription order is processed.*
Classic Pharmacy: 718-727-0022
- Yes, I agree to call Classic Pharmacy.
Signature
Signature required upon delivery
Date*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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