test - Immigration Spot Clinic

IMMIGRATION NEW PATIENT INTAKE FORM

Please Upload Form of ID:(Ex: Passport, Visa or Driver's License) - NAME MUST MATCH GOVERMENT ID

Name/Nombre*

Address\Dirección(No P.O. Boxes)*

DOB (Date of Birth)/Fecha de nacimiento*

Requested Date of Appointment/Fecha solicitada de la cita

Gender/Genero*

MaleFemale

Country of Birth/País de nacimiento*

City of Birth/Ciudad de nacimiento*

AGE/EDAD*

Phone/Telefono*

Email*

Alien Number/Número de extranjero

Do you have Health Insurance?/Tienes seguro médico?*
yesno

Insurance Name\Nombre de seguro médico?*

Upload Insurance Card (Front)*

Patient Status*

Medical Information

Allergies/Alergias*
yesno

If yes, please provide medication name or food allergy.\ Indique el nombre del medicamento o la alergia a comida*

Do you have a fever, diarrhea, or vomiting today?

YesNo

Are you allergic to eggs, Baker’s yeast, preservatives (i.e. sulfites), thimerosal, streptomycin, neomycin, Arginine, gelatin or latex?

YesNo

Have you ever had a severe reaction to any vaccine which required medical care?

YesNo

Have you received any vaccines in the past 4 weeks?

YesNo

History of Varicella disease "Chickenpox", "Lechina", "Catapora"

YesNo

For women: Are you pregnant or planning pregnancy in the next month?

YesNo

Please place a check next to any health conditions listed below that apply:
DiabetesHigh Blood PressureHeart DiseaseLung DiseaseKidney DiseaseLiver DiseaseHepatitisHIV/AIDSCancerArthritisStrokeDepressionAnxietyOther

Current Medications*
yesno

If yes, please write name, dose and frequency*
(Example Format: Tylenol, 325mg, Every 12 Hours)

Question\Pregunta

Who's helping you with the Adjustment of status form I-485?/¿Quién lo está ayudando con el formulario de Ajuste de Estatus I-485?*

Would you like some information about our Immigration Document Preparation services?\¿Quiere información sobre nuestros servicios de Preparación de Documentos de Inmigración?*
YesNo

Covid vaccination card and vaccination records

Have you been vaccinated for Covid-19?
yesno

Please upload a picture of the vaccine card (front)*

Do you have any other vaccination records or labs results including immunication titers?
yesno

Please upload vaccination documentation*

I-693 Form Release

Is the patient younger than 18?/¿El paciente es menor de 18 años?
yesno

Who will pick up the I-693 form?/¿Quién recogerá el formulario I-693?

Full Name

Date of Birth

Who will pick up the I-693 form?/¿Quién recogerá el formulario I-693?

Full Name

Date of Birth

Disclosures

1. Patient is acknowledging that all demographic information is accurate and was reviewed today. Patient is also acknowledging that physical, blood work and vaccinations must be completed in order for us to complete the I-693 Form. I-693 Form can take up to seven business days or more.
Patient is acknowledging that all information is accurate and was reviewed today. I’m aware that form I-693 can take up to five business days or more.

2. Any changes to a completed I-693 Form will have minimum fee of $95.00 and will take ten (10) business days to complete.

3.USCIS is shortening the I-693 validity period to 60 days from the date the Civil Surgeon signs the I-693 medical exam. Form I-693 medical report will be valid for two years from the date of submission to USCIS Important Information (I-693 EXPIRATION).

4. Immigration Medical Exam form I-693 must be picked up within 60 days of the completion date.

5. I am responsible to pay an additional fee of $40 if my first syphilis test result is positive.

6. You must complete all I-693 requirements within 30 days of your initial visit - Exception for abnormal lab results. Immigration exams are NOT covered by INSURANCE and are considered SELF PAY service. We will not submit any claims to insurance for payment. Therefore, we are not responsible for any invoices you may receive from any Pharmacy or Laboratory.

7. We don’t complete or certify any other Immigration forms regarding disability, waivers etc.

8. Please sign that you have received our HIPAA notice of privacy practices
I have read, or have had read to me, the provided Vaccine Information Statement(s) (“VIS”).I have had the opportunity to ask questions about the Vaccine, and all my questions have been answered to my satisfaction. I understand the benefits and risks of the vaccine(s). I consent to the administration of the vaccine(s) requested. I authorize this information to be forwarded to my primary care physician, the authorizing physician, or the local Dept. of Health, if applicable. I agree to stay in the general area for 15 minutes after receiving my vaccination in case any immediate reactions occur. I understand that if I experience any side effects, I am responsible for following up with my physician at my expense. On behalf of myself, my heirs, and my personal representatives, I hereby release the company that is administering the vaccine(s); Immigration Spot Clinic the subsidiaries and affiliates of Immigration Spot Clinic the respective directors, officers, employees, and agents of Immigration Spot Clinic and its subsidiaries and affiliates; and the owner and/or operator of the clinic site and its directors, officers, employees, and agents from any and all liability that might arise from this vaccination.

9. I grant permission to Immigration Spot Clinic & Services to use images and/or videos taken for the purpose of advertisement and promotion including, but not limited to, our website, our social media accounts, and our promotional materials, either digital or in print. I understand that I may revoke this authorization at any time by notifying us in writing. I also waive any rights of privacy or compensation associated with the use of my image.

Refund Policy: All services rendered by the Immigration Spot Clinic are provided on a non-refundable basis.

Name

Today Date

I AGREE WITH DISCLOSURE
Yes-$25

Note: "Please wait after submitting the form. It may take a minute to process. Do not leave the page." Once the form submission is complete, you will be redirected to a secure payment page to deposit a mandatory $25 appointment fee.

IMMIGRATION NEW PATIENT INTAKE FORM

Medical Information

Question\Pregunta

Covid vaccination card and vaccination records

I-693 Form Release

Disclosures

Contact Info

Address

Working Hours