Patient Forms
InteCare Medical Clinic Patient Forms
Thank you for selecting Dr. David A. Zainey at InteCare Medical Clinic in Fairborn, Ohio, for your integrative medicine care. To schedule an appointment, please call us at (937) 874-5766, download, print and email our request an appointment form to MA124@InteCareMedicalClinic.com , or use our online appointment request form.
Once you have made your initial appointment, you may preregister by downloading, printing, and completing the forms on this page. Doing so prior to your visit will help speed up the new patient registration process.
Please be sure to bring forms with you to your first visit, along with any medical records supporting your diagnoses, that may not have been already faxed to us by your physicians.
Established patients can update forms online through our Patient Portal. If you need help accessing the portal, please call the office and we’ll be happy to help.
Downloadable Forms:
- Request an Appointment
- New Patient Registration
- Health History
- Medical Records Release
- Substance Use Disorder Permission for Medical Marijuana Treatment
Please note: It may take a few minutes to load the forms if you are using a slow internet connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the icon below.
