Australian Immigration Form

Medical Examination for an Austalian Visa Form 26

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 of Signature

How to complete this form

Applicant

Complete Part A and Part B before attending the medical examination. All questions must be answered.
Complete Part C in the presence of the examing physician.

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Upload Image of your Passport

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Upload a Recent Passport Size Photograph of Yourself.

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Email

Part A- Applicant's Details

To be completed by the applicant before attending the medical examination.

1. Your HAP ID

2. Your full name (as it appears in your passport)

First Name

Last Name

Middle Name

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

4. Gender

Select One Choice

Male
Female
Indeterminate/Intersex/Unspecified

5. Your telephone numbers

Office Hours

After Hours

6. Your Residential Address

Unit/Apt #

City

State

Zip

7. Intended occupation/activity in Australia

8. Countries in which you have spent more than 3 consecutive months in the last 5 years

9. How long do you intend staying in Australia?

Select One Choice

Permanently
Temporarily

If Temporarily, List for how long in years and months:

10. If you are applying for a temporary visa, would you like your health to be assessed 'up front' for a permanent stay in Australia?

Select One Choice

No
Yes, Additional medical examinations may be required.

11. If you are in Australia: How long have you been here in years and months?

11. If you are in Australia: What visa subclass do you currently hold?

12. What is the visa subclass number and name of the visa that you are applying for? For more information please refer to page 1 of this form.

13. Are you:

Select what applies. All unchecked boxes will be marked No

(a) a protection visa applicant?
(b) an unaccompanied minor refugee child?
(c) a refugee?
(d) a child for adoption by an Australian resident?
(e) an Australian State or Territory Welfare Supported child?
(f) a non-migrating family member of an applicant?
None of the above

14. In Australia, will you be:

Select what applies. All unchecked boxes will be marked No

(a) Attending or teaching classes?
(b) Working in childcare/creche?
(c) Working or studying to be a doctor, dentist, nurse or paramedic?
None of the above

Part B- Applicant's Medical History

To be completed by the applicant before attending the medical examination.

15. Have you ever been diagnosed with or had to take treatment for, Tuberculosis (TB)?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

16. Have you ever been in close contact at home with a person known to have Tuberculosis (TB)?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

17. Have you ever had prolonged medical treatment and/or repeated hospital admissions for any reason (including for a major operation or psychiatric illness)?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

18. Do you suffer, or have you ever suffered, from mental health problems?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

19. Have you ever been told you are HIV positive?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

20. Do you have, or have you ever had, hepatitis, problems with your liver or yellowing of the skin?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

21. Do you have, or have you had, cancer in the last 5 years?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

22. Do you have high blood sugar/diabetes?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

23. Do you have heart problems, including high blood pressure or a heart condition that you were born with?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

24. Do you have a blood condition?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

25. Do you have bladder or kidney problems?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

26. Do you have a physical or intellectual disability that make it difficult for you to function (for example, to move around or learn) or work full-time?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

27. Do you need to take drugs or drink alcohol regularly?

Select One Choice

No
Yes

If yes, list the relevant details, including dates

28. Please list any prescribed pills or medication (excluding oral contraceptives, over-the-counter medication and natural supplements) you are taking.

29. For female applicants- Are you pregnant?

Select One Choice

No
Yes

If yes, what is the expected date of birth? (day, month, year)

How to complete Radiological Report Form 160

Chest X-Ray is Required for Ages of 11 years and older

Applicant

Complete Part A (with the exception of the "Pregnant visa applicant's declaration") before attending the radiological examination. All questions must be answered.
Complete Part B in the presence of the radiographer.

Radiological Report on Chest X-Ray of an Applicant for an Australian Visa Form 160

Cost Not included in Immigration Physical Exam.

Chest X-Ray (ONLY) $110

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 of Signature

How to complete Radiological Report Form 160

Chest X-Ray is Required for Ages of 11 years and older. Cost NOT included in Immigration Physical.

Applicant

Complete Part A (with the exception of the "Pregnant visa applicant's declaration") before attending the radiological examination. All questions must be answered.
Complete Part B in the presence of the radiographer.

Radiographer

Certify in writing across the top of the photograph and on the form (without obliterating the image) that it is a true likencss of the examine. Date to be included.
Sight valid passport/national identity card (if provided) and record passport/national identity card number below.
You must ensure the applicant has provided answers to all the questions in Part A before the applicant signs the declaration at Part B.
Complete Part C.

Radiologist

Complete Part D.

Part A- Applicant's Details

To be completed by the applicant before attending the radiological examination.

1. Your HAP ID

2. Your full name (as it appears in your passport)

Family Name

Given Names

Middle Name

3. Date of Birth

4. Gender

Select One Choice

Male
Female
Indeterminate/Intersex/Unspecified

5. Your telephone numbers

Office Hours

After Hours

6. Your Residential Address

Unit/Apt #

City

State

Zip

7. Intended occupation/activity in Australia

8. How long do you intend staying in Australia?

Select One Choice

Permanently
Temporarily

If Temporarily, List for how long in years and months:

9. If you are in Australia: How long have you been here in years and months?

9. If you are in Australia: What visa subclass do you currently hold?

10. What is the visa subclass number and name of the visa that you are applying for? For more information please refer to page 1 of this form.

11. Have you undertaken a health examination for an Australian visa in the last 12 months?

Select One Choice

No
Yes

If Yes, Give details (including HAP ID if available)

12. For female applicants: Are you pregnant?

Select One Choice

No
Yes

If Yes, What is the expected date of birth?

Thank you for contacting us!

Thank you for contacting Neighborhood Medical Center. We appreciate your interest in our services and for taking the time to fill out our forms.

Please call our office at 972-726-6464, or book online through Zocdoc HERE to schedule your appointment.

We look forward to serving you and providing you with exceptional healthcare services.

Warm regards,

Neighborhood Medical Center Team

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