Canadian Immigration Physical

ATTENTION CANADIAN IMMIGRATION MEDICAL CLIENTS

Adult (15 Years & Above)

IF YOU DO NOT HAVE AN IME/UCI FILE NUMBER, PLEASE ANSWER THE FOLLOWING QUESTIONS:

PROPOSED VISA APPLICATION DETAILS UP-FRONT MEDICAL TYPE

FAMILY EDE (NO LONGER AN OPTION FOR UPFRONT MEDICAL NEED IME NUMBER) AS OF DEC, 15, 2016
STUDENT
VISITOR
WORKER

I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS ACCURATE. WE CREATE YOUR FILE BASED ON THIS INFORMATION.

Name

Date of Birth

Signature

To accept this contract, type your name below

Date of Signature

Canadian Examination Application

Legal Last Name On Passport/ID

Legal First Name On Passport/ID

Legal Middle Name On Passport/ID

Date of Birth (mm/dd/yyyy)

Phone Number

Gender

Select One

Male
Female
Other

Mailing Address

Unit/Apt #

City

State

Zip

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

PRESCRIBED MEDICATION QUESTIONNAIRE

THIS SMALL QUESTIONNAIRE PERTAINS TO MEDICATION AND DIAGNOSIS. PLEASE KEEP IN MIND THAT IF THIS IS NOT ANSWERED ADEQUATELY PAPERWORK WILL BE DELAYED.

Are You Taking Any Prescribed Medications?

1. List one medication and reason for taking it.

2. List one medication and reason for taking it.

3. List one medication and reason for taking it.

4.. List one medication and reason for taking it.

5. List one medication and reason for taking it.

6. List one medication and reason for taking it.

7. List one medication and reason for taking it.

CLIENT CONSENT AND DECLARATION

Client Consent - (Client 16 years and over)

I, the client, declare that all information provided by me during my immigration medical examination in support of my application to Citizenship and Immigration Canada (CIC) is true, correct and complete. I have reviewed the medical history information provided by me and declare it is true, correct and complete.
I give my consent and authorization for the panel physician, radiologist, and health workers or hospital to collect and report the results of my immigration medical examination to CIC.
I understand that CIC:

may release the information collected related to my immigration medical examination to, and
may collect medical information about me from a federal, provincial or territorial public health or social service agency in
Canada, or a physician or health worker in Canada for purposes related to the administration of Canada's Immigration and
Refugee Protection Act or to protect the health and safety of Canadians and
will use and disclose my information in a manner that is consistent with Canadian privacy law applicable to CIC.

This information is provided in support of my application to CIC and is collected under the authority of the Immigration and Refugee Protection Act. It will be used to render a decision regarding this application and may be used for future applications. The information is retained to maintain a record of my application for the purpose of the administration of the Act. The
information will be retained in the Personal Information Banks of CIC being CIC PPU 051, CIC PPU 054, or CIC PPU 055, depending upon the type of application made, as well as in CIC APB 012, CIC PPU 042 and CIC PPU 051.

I, the client, have read and understand this notice and consent. I provide my consentvoluntarily by signing this form.

I understand that misrepresentation by an applicant providing false or misleading information is an offence under section 127 of Canada's Immigration and Refugee Protection Act and may result in a finding of inadmissibility to Canada or removal from Canada.

I have read and understand this notice and consent. I provide my consent voluntarily by signing this form.

To accept this contract, type your name below

I understand that misrepresentation by an applicant providing false or misleading information is an offense under section 127 of Canada's Immigration and Refugee Protection Act and may result in a finding of inadmissibility to Canada or removal from Canada.

Client's Family Name

Client's Given Name(s)

Date of Birth

Signature of Client

To accept this contract, type your name below

Date of Signature

MEDICAL REPORT

MEDICAL HISTORY QUESTIONS

UCI number

IME number

UMI number (if applicable)

Family Name

Given Name(s)

Date of Birth

IF YOUR ANSWER IS YES TO ANY OF THE FOLLOWING QUESTIONS, PLEASE PROVIDE ADDITIONAL INFORMATION INCLUDING:

DIAGNOSIS, DATE, AND TREATMENT (INCLUDING MEDICATIONS AND/OR MAJOR SURGERIES)

1. Tuberculosis (TB), treatment for tuberculosis

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