Patient Intake

Patient Intake Form

Please complete this form to help us prepare for your evaluation. All information is kept strictly confidential.

This form helps Dr. Davenport's team understand your medical history and aviation background before your evaluation. Please fill out all fields as completely as possible.

Privacy Notice: This form is transmitted securely via Netlify. For medical records and imaging files (which may be large), we will provide a separate HIPAA-compliant secure upload link after reviewing your intake information.

Contact Information

First Name *

Last Name *

Email * Please enter a valid email address

Phone * This field is required

Date of Birth *

State of Residence

Mailing Address

Aviation Background

Pilot Certificate Type *

Class of Medical Needed *

Current Medical Certificate Status *

Medical Information

Primary Cardiac Condition *

Brief Description of Event / Condition * This field is required

Date of Event / Diagnosis

Current Cardiologist / Physician

Current Medications

What Brings You to MACH I?

Primary Goal *

Additional Information

By submitting this form, you acknowledge that this is a preliminary intake only. A member of our team will review your information and contact you to discuss next steps, including scheduling and any additional records needed.

What Happens Next?

We Review Your Intake

Dr. Davenport's team reviews your submission within 1-2 business days.

Initial Discussion

We'll call you to discuss your case, answer questions, and assess candidacy.

Records Collection

If you're a candidate, we'll send you a condition-specific checklist and a secure upload link for your medical records.

Evaluation Scheduled

Once records are received and reviewed, we'll schedule your comprehensive evaluation ($1,200).

Have a quick question before filling out the intake form?

Ask a Question

Prefer to call? (937) 668-6974 — Mon-Fri 8:00 AM - 5:00 PM EST