Immigration Information

IMMIGRATION I693 INFORMATION

First name

Middle Name

Last name

Birthday

Día

Mes

Año

Multi-line address

País/región

Dirección

Ciudad

Código postal

Phone

Sex

Female

Male

City/Town/Village of Birth

Country of Birth

Alien Registation number

Phone

IDENTIFICATION TYPE (PASSPORT, ID , EMPLOYMENT AUTHORIZATION)

DOCUMENT IDENTIFICATION NUMBER

REQUIRED INFECTIOUS SCREENING

We do not accept outside lab results for REQUIRED INFECTIOUS SCREENING. All testing must be completed in our office!!

All immigration patients require QUANTIFERON GOLD PLUS

Patients age 18–44 require SYPHILIS / RPR

Patients age 18–24 require GONORRHEA (GC & CHLAMYDIA URINE

IMMUNITY / VACCINATION TITERS

Please complete your vaccination record as thoroughly as possible. If you do not have certain records or do not have them with you, that is fine. However, you must bring all available vaccination documents to your physical exam. We do not accept any additional submissions after the exam. Please ensure you bring all records listed below, along with any additional documentation, on the day of your exam.

DT/DTap/DTP Date Received (mm/dd/yyyy)

Tp/Tdap Date Received (mm/dd/yyyy)

OPV/IPV Date Received (mm/dd/yyyy)

MMR (Measles, Mumps, Rubella) Date Received (mm/dd/yyyy)

Hib (Haemophilus influenzae type B) Date Received (mm/dd/yyyy)

Hepatitis B Date Received (mm/dd/yyyy)

Hepatitis A Date Received (mm/dd/yyyy)

Varicella Date Received (mm/dd/yyyy)

Pneumococcal Date Received (mm/dd/yyyy)

Influenza Date Received (mm/dd/yyyy)

Rotavirus Date Received (mm/dd/yyyy)

Meningococcal Date Received (mm/dd/yyyy)

COVID-19 Date Received (mm/dd/yyyy)

Please bring your vaccination records if you have them. If you are missing any required vaccines or do not have proof of vaccination, you will need to complete blood tests (immunity titers). These tests are not included and will require an additional fee. Pricing varies depending on the type of vaccine being tested.

Lawyer Name ( if available)

Lawyer Phone Number ( if available)

Lawyer Email ( if available)

Please upload all files support this form ( ID, passport, vaccination, ect.)

Signature

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