Wellness Appointments

Mustang Drug
103 E State Highway 152
Mustang, OK 73064

405-256-0555
contact@mustangdrug.com

Point-of-Care Testing

Patient Intake & Assessment Form

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

Email *

Sex *

Race *

Which test are you requesting? *

Allergies: *

Primary Care Physician:

Office Phone Number:

(###)

###

####

Current Medications:

Past Medical History:

When did your symptoms start?

MM

DD

YYYY

Have you taken any medications for these symptoms? *

If yes, what and when?

Did you receive the COVID-19 Vaccine? *

If yes, which vaccine?

Did you get the flu shot this year? *

Which of these symptoms do you currently have? *

Fever

Muscle Pain

Runny Nose

Fatigue

Loss of Taste

Headache

Sore Throat

Cough

Head/Nasal Congestion

Shortness of Breath or Trouble Breathing

No Symptoms

any other symptoms not listed above:

Thank you for filling out our assessment form.

We request that you wear a mask while interacting with our staff members unless instructed otherwise.

A staff member will be calling you shortly for payment information and vehicle description.

Mustang Drug
103 E State Highway 152
Mustang, OK 73064

Phone: 405-256-0555
Email: contact@mustangdrug.com

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