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Secure Immigration Medical Application Form

Each family member will require a separate form. Family sponsors will require IME#. All others – UCI#.

After you submit this form, a staff member will call you to confirm the appointment.

All fields must be completed. If you do not know the answer, please put a zero.

Immigration Medical Form Submission

Immigration Type

IME # (if available)

First Name

Last Name

Middle Name

Email

Gender

Date Of Birth

Address (current, in Canada)

City

Postal Code

Cell Phone for text msg.

ID Type

Country Of Birth

ID Issuing Country

ID Number

ID Issue Date

ID Expiry Date

Have you had an examination in our office before? Have you had an examination in our office before? Yes No

Are you a single applicant or a family of multiple applicants? Are you a single applicant or a family of multiple applicants? single multiple

Please provide additional details about your request:

I have read and agree to the Terms and Conditions:

11 + 15 =