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Contact Info
Mustang Drug
103 E State Highway 152
Mustang, OK 73064
405-256-0555
contact@mustangdrug.com
New Patient Intake 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
Gender
*
Male
Female
Email
Notification Preference
*
Text
Email
Text & Email
None
Allergies/Medical Conditions
Allergies and Reactions (ex. penicillin-rash)
*
Type "None" if no allergies
Medical Conditions (check all that apply)
*
Hypertension (I10)
Type 2 Diabetes (E11.9)
Type 1 Diabetes (E10.9)
Hypothyroidism (E03.9)
Hyperlipidemia (E78.5)
Anxiety (F41.1)
Depression (F32.9)
Acid Reflux (K20.9)
None
Other conditions not listed:
Insurance Information
Insurance Type
*
Medicare
Medicaid
Commercial
No Insurance
Rx ID:
Rx BIN Number
Rx Group:
Customer Service Phone Number:
Current Medications
Prescriptions Medications/Supplements:
*
Type "None" if not taking any prescription medication or supplements
Services We Offer
- Medication Synchronization Program (MedSync)
Tired of making multiple trips to the pharmacy? Our MedSync Program helps you align all your prescription refills to be ready on the same day each month. It simplifies your routine, improves medication adherence, and saves you time.
Would like to enroll in the Medication Synchronization Program?
Yes
No
Would like more information
Did you know we offer these services? Check all that you are interested in or would like more information about:
Prescription Delivery (Tuesdays & Thursdays)
Compounding Services (customized medications)
Hormone Consultation & Lab Testing
Nutritional Supplements & Vitamins Consultations
Immunizations (Flu, Shingles, Pneumonia, etc.)
Medication Reviews with a Pharmacist
Pet Medications
Would you like a team member to follow up with you about any of these services?
Yes
No
By electronically signing below, I acknowledge that I am either the patient listed above or an authorized caretaker of the patient listed above and that the information listed is complete and accurate to the best of my knowledge. I am aware that incomplete answers could negatively affect the patient listed above.
*
E-Signature
Date
MM
DD
YYYY
Thank you!
