Prescription Services for Muhlenberg Students. Newhard Pharmacy will deliver prescriptions, durable medical equipment and any items for sale in our retail store at no charge to Muhlenberg students via a daily (Monday-Friday) delivery to Health Services during days school is in session. Please fill out this form to set up your student as a new patient.

Student name & Date of Birth: *

Medical Insurance Card Front

Medical Insurance Card Back

Prescription Insurance Card Front

Prescription Insurance Card Back

Billing Address

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Credit Card Type *

Name on Card *

Credit Card Number *

Expiration Date *

CVV *

Signature *

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