Creative Care Pharmacy
14101 N Eastern Ave Suite A
Edmond, OK 73013

405-562-1800
contact@creativecarerx.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? *

Do you have Medicare Part-B?

Yes

No

If yes, please provide Medicare Part-B ID number

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.

Once you arrive to the store please call the pharmacy at 405-562-1800 to provide payment information and vehicle description.

Creative Care Pharmacy
14101 N Eastern Ave Ste A
Edmond, OK 73013

405-562-1800
contact@creativecarerx.com

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