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Celebrity Cosmetic Dermatologist

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Immigration Medical Examination Referral

Law Office Patient Referral for USCIS Form I-693

Law Firm Information

Law firm name*

Attorney name*

Attorney email*

Office phone number*

Law firm address*

Patient Information

Patient first name*

Patient last name*

Date of birth*

Día

Mes

Año

Patient phone number*

Patient email

Patient address

País/región*

Dirección*

Ciudad*

Código postal*

Immigration Case Details

Immigration category*

USCIS receipt number

Priority date

Examination urgency*

Standard (2-4 weeks)

Expedited (1-2 weeks)

Rush (Within 1 week)

Medical History

Known medical conditions

Diabetes

Heart disease

Mental health conditions

Tuberculosis history

Substance abuse history

Communicable diseases

Other condition

Required vaccinations status

Up to date with all vaccinations

Missing some vaccinations

No vaccination records available

Religious/medical exemptions

I confirm that the patient has been informed about the immigration medical examination requirements

Additional notes or special circumstances

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Shipping & Return Policy

Term & Condition

1035 Sterling Rd, Unit 104, Herndon, VA 20170

Tel:703-840-0610

Fax:571-323-3243
primehealth1041@gmail.com

Monday 7:00AM–3PM

Tuesday 7:00AM–3PM

Thursday 7:00AM–3PM

Friday 7:00AM–3PM

Saturday 10AM-3PM

Lunch time 11:30am - 12pm

Wednesday Closed

Sunday Closed

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