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 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 diagnostic films or other test results that may have been ordered or performed by another physician.
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:
- 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.
