iMed Urgent Care - Patient Intake Portal

Part 1. Information About You

Applicant

1. Your Full Legal Name *

Do not provide a nickname

Family Name (Last Name) *

Given Name (First Name) *

Middle Name (if applicable)

2. Current Physical Address

Street Number and Name *

Apt. / Ste. / Flr.

City or Town *

State *

ZIP Code *

Country

3. Other Information

A. Sex *

MaleFemale

B. Date of Birth *

C. City/Town/Village of Birth

D. Country of Birth *

E. Alien Registration Number (A-Number)

F. USCIS Online Account Number

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

Applicant

Applicant's Contact Information

1. Daytime Telephone Number

2. Mobile Telephone Number (if any)

3. Email Address (if any)

Applicant's Certification and Signature:

I certify, under penalty of perjury under U.S. law, that this form I-693 I have filed is complete, true, and correct. I understand that all of the information that I have provided will be used to determine my eligibility for the immigration benefit I am seeking.

I further certify that I understand the medical tests and examinations required to complete the medical examination. I understand that the civil surgeon will disclose my medical information to USCIS for adjudication of my immigration benefit.

Date of Signature

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

Interpreter

1. Family Name (Last Name)

Given Name (First Name)

3. Daytime Telephone Number

4. Mobile Telephone Number (if any)

5. Email Address (if any)

Interpreter's Certification: I certify, under penalty of perjury, that I am fluent in English and the designated language, and that I have fully translated all instructions, questions, and responses for the applicant.

Date

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

Preparer