Have You Brought with You the Following?

Have You Brought with You the Following?

CIVIL SURGEON PATIENT INTAKE FORM

Have you brought with you the following?

Put your name and DOB in the right upper corner ofeach page

Original and PHOTOCOPY OF (there is a surcharge of $1/page of photocopy service at the clinic)

  • Government-issued photo identification, such as a valid passport or driver’s license.
  • Relevant medical records (must be in English)
  • Vaccination or immunization record (must be in English)
  • Proof of prior treatment for TB or other infectious disease(s), if any

Medical insurance card, if any (may cover some of the tests required)

Payment (money order or cash). No personal check or credit card.

Sign & dateevery page of this document

PATIENT INFORMATION:

Last name / Pharmacy address
First name
Middle name
Cell phone
Email / Home address
Primary care MD
Alien registration number
CITY/TOWN OF BIRTH / Country of birth:
Date of birth:

CURRENT MEDICATION:

Name / Dose / Frequency

DRUG ALLERGIES:[ ] NO; [ ] YES: ______

ANY DISEASES RUN IN FAMILY: [ ] NO; [ ] YES: ______

SOCIAL HISTORY:

No / Yes
SMOKE
ALCOHOL
RECREATIONAL DRUG USE
OCCUPATION:
HARMFUL BEHAVIOUR

Circle the symptoms if you have any

General symptoms:
Fever, swollen glands, change in vision, hearing loss, sore throat, runny nose, skin changes, joint/muscle pain, oral/genital sores, rash,change in weight, change in appetite / Neurological:
Headaches, weakness, loss of sensation, numbness, falling, dizziness, depression, anxiety / Genitourinary:
Burning sensation while urinating, blood in urine, genital discharge, genital itching
Heart and Lungs:
Chest pain, irregular heartbeat, cough, sputum, blood in sputum, wheezing, shortness of breath, abnormal chest x-ray / Abdominal:
Nausea, vomiting, jaundice, abdominal pain, heartburn, difficulty swallowing, diarrhea, constipation, bloody stools / Other:
MAJOR ILLNESS / YES / NO / DATE OF ONSET / PHYSICIAN NOTE
ASTHMA
TUBERCULOSIS
HEART PROBLEMS
HYPERTENSION
THYROID DISEASE
STROKE
SEXUALLY TRANSMITTED DISEASES
HIV/AIDS
DIABETES
REFLUX/HIATAL HERNIA
GALLBLADDER DISEASE
HEPATITIS/JAUDICE/LIVER DISEASE
COLITIS/CROHN’S DISEASE
CANCER
HEADACHE
MENTAL DISORDER
DEPRESSION/ANXIETY
SEIZURE/EPILEPSY
PHYSICAL IMPAIRMENT
OTHERS
Find Quest Diagnostic closest to you:

Fill out as much as you can / Date received
(mm/dd/yyyy) / Date received
(mm/dd/yyyy) / Date received
(mm/dd/yyyy) / Date received
(mm/dd/yyyy)
DT/DTap/DTP
Td/Tdap
OPV/IPV
MMR
Hib
Hep B
Varicella
Pneumococcal
Influenza
Rotavirus
Hep A
Meningococcal

Our goal is to complete your i693 accurately and effectively within 1 week, while keeping your cost to the minimum. By signing below, you indicated that you understand:

  1. Payment is non-fundable and upfront. Cash or money order only.
  2. Please bring your own copies of all necessary documents (see p.1). The application fee does not cover photocopying services. If you prefer, we can make photocopy for you with a surcharge of $1/page.
  3. First visit usually 45 minutes, but can be up to 1.5 hr.
  4. It usually takes 1-2 visits to our clinic to complete the form
  5. If you do not obtain recommended vaccines or blood work within 5 business days after your first visit, we will close your file and payment is non-refundable. There is a $100 fee to re-open your file.
  6. Your paperwork is usually ready within 3 business days after all the necessary requirements are fulfilled.
  7. On the day of picking up yourcompleted i693 form, the visit may take up to 45 minutes (we have a rigorous verification process in place to ensure accuracy, 2trained staff will independently review and verify your completed form).
  8. Your fee include a digital PDF copy of your completed i693 form.Additional hard copy is available for $5 each.
  9. Recommendations will be made regarding what vaccines need to be administrated to complete the application, per CDC guidelines. Applicants have the option to receive the vaccine in the clinic for additional feesor receive them directly at nearby CVS or Walgreen (lower cost to patients with or without insurances).
  10. Recommendations will be made for lab work. Applicants have the option to get lab samples collected in our clinic for an additional $50, or have lab done directly at nearby Quest Diagnostics to avoid the handling fee (lower cost to patients with or without insurances).
  11. The immigration medical exam is intended to be a “snapshot” of the applicant’s medical status. Therefore, the chest X-ray and lab results should be closely related in time to the physical examination. While there is no defined period of time during which a chest X-ray or lab work is “valid,” we STRONGLY advise that you obtain lab work and other i693 related studies AFTER your first visit with us. We will tell you exactly what studies you need and work with your local lab to order them if you prefer obtaining them locally. Results usually available in 72 hours, dependent on your labs. If lab work were obtained from lab other than Quest Diagnostics, applicants are responsible of obtaining and sending us the report. We are not responsible for obtaining your outside records.

Please sign and date here to certify the above information is true: ______( / /2016)

Civil surgeon intake form updated on 10-26-2016 JL

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