United States Immigration Physical

USCIS Physical Examination Application Information

Upload Image of your COVID-19 Vaccination Card

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Upload Image of your Passport

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Legal Last Name On Passport/ID

Legal First Name On Passport/ID

Legal Middle Name On Passport/ID

Date of Birth (mm/dd/yyyy)

Gender

Select One

Male
Female
Other

Mailing Address

Unit/Apt #

City

State

Zip

Phone Number

Type of Identification

Select One

License
Passport

Identification Number

Expiration Date

Country or State Issued

Issue Date

Patient Signature

I acknowledge the charges and agree to pay the total at the end of the visit with NO INSURANCE or HSA. I understand that additional charges may be necessary.

Date

Report of Immigration Medical Examination and Vaccination Record

Part 1. Information About You (To be completed by the person requesting a medical examination, NOT the civil surgeon)

1. Your Full Legal Name (Do Not provide a nickname)

Full Legal Family Name (Last Name)

Full Legal Given Name (First Name)

Full Legal Middle Name (if applicable)

2. Current Physical Address

In Care Of Name (if any)

Street Number and Name

Checkbox Title

Checkbox Description

Apt.
Ste.
Flr.

Number

City or Town

Province

State

Zip Code

Postal Code

Country

3. Other Information

A. Gender

Select one option

Male
Female

B. Date of Birth (mm/dd/yyyy)

C. City/Town/Village of Birth

D. Country of Birth

E. Alien Registration Number (A-Number) (if any)

F. USCIS Online Account Number (if any)

4. Immigration Medical Examination Requirement

A. I am eligible for completion of the vaccination record portion only, because I previously completed an overseas immigration medical examination, signed by a panel physician (refugee or derivative asylee adjustment of status applicants under Immigration and Nationality Act (INA) section 209 and K nonimmigrant visa holders applying for adjustments of status).

NOTE: If you selected this box for Item A. in Item Number 4., you, the applicant, and the civil surgeon are responsible for completing Parts 1. - 5., Part 7., and Part 10.

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

Part 2. Applicant's Statement, Contact Information, Certification, and Signature

Applicant's Contact Information

Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).

1. Applicant's Daytime Telephone Number

1. Applicant's Mobile Telephone Number (if any)

Applicant's Email Address (if any)

Applicant's Certification and Signature

I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted with my application, I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in Part 3., understood, all of the responses and information contained in, and submitted with, my form, and that all of the responses and the information are complete, true, and correct. I understand the purpose of this immigration medical examination, and I authorize the required tests and procedures to be completed. If it is determined that I willfully misrepresented a material fact or provided false or altered information or documents with regard to my immigration medical examination, I understand that any immigration benefit I derived from this immigration medical examination may be revoked, that I may be removed from the United States, and that I may be subject to civil or criminal penalties. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for an immigration request and to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.

NOTE: Do not sign or date Form I-693 until instructed to do so by the civil surgeon.

Applicant's Signature

To accept this contract, type your name below

Date of Signature

Part 3. Interpreter's Contact Information, Certification, and Signature

Interpreter's Full Name

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

Interpreter's Business or Organization Name

Interpreter's Contact Information

Interpreter's Daytime Telephone Number

Interpreter's Mobile Telephone Number (if any)

Interpreter's Email Address (if any)

Interpreter's Certification and Signature

I certify, under penalty of perjury, that I am fluent in English and the patient's language, and I have interpreted every question on the application and instructions and interpreted the applicant's answers to the questions in that language, and the applicant informed me that they understood every instruction, question, and answer on the application.

List the Patient's Language Here

Interpreter's Signature

To accept this contract, type your name below

Date of Signature

Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant

Preparer's Full Name

Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

Preparer's Business or Organization Name

Preparer's Contact Information

Preparer's Daytime Telephone Number

Preparer's Mobile Telephone Number (if any)

Preparer's Email Address (if any)

Preparer's Certification and Signature

I certify, under penalty of perjury, that I prepared this application for the applicant at their request and with express consent and that all of the responses and information contained in and submitted with the application are complete, true, and correct and reflects only information provided by the applicant. The applicant reviewed the responses and information and informed me that they understand the responses and information in or submitted with the application.

Preparer's Signature

To accept this contract, type your name below

Date of Signature

United States Immigration Physical

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