Registration Form

Please Bring the Following:

Two Government issued ID's ( Passport, TXDL, Visa )
Notice of Action Letter ( Form I-797 )
Request for Evidence ( RFE )
Employment Authorization Card
Vaccine Records
Covid-19 Vaccine Card

Date

Immigration & Naturalization Registration Form

First Name

Middle Name

Last Name

Date of Birth

Age

Gender

Male Female

Address: Street Number/Name

Apartment Number

City

State

Zip Code

City/Town of Birth

Country of Birth

Alien Registration Number ( A Number, if any)

Email address

Telephone Number

Type

Mobile Home Work Other

Disclosures

Patient is acknowledging that all demographic information provided is accurate and was reviewed today.
Immigration exams are NOT covered by insurance and are considered Self pay. We will not submit any claims to insurance for payment.
We do not complete or certify any other immigration forms regarding disability, waivers, etc. The only documents we complete are the USCIS Form I-693.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Legal Guardian

Patient Medical History

First Name

Middle Name

Last Name

Date of Birth

Age

Gender

Male Female

Marital status

Single Married Divorced Widowed Significant Other

Employment Status

Full Time Part Time Unemployed Retired Student

Use of Alcohol

Yes No

Drinks / Week

Street Drugs

Yes No

Use of Tobacco

Yes No

Packs / Day

Have you ever had surgery or been Hospitalized?

Yes No

If Yes please list dates/reason

CURRENT MEDICATIONS

Drug Allergies

Yes No

If yes to what?

Please list any medications that you are taking now:

Add Medication

MEDICAL ILLNESSES

If other, please specify.

COMMENTS

COVID-19 Questionnaire

Name

Date

DOB

Temperature

Do you have any of the following symptoms?

Persistent Pain/Pressure in Chest

Yes No

Headache

Yes No

Diarrhea

Yes No

Nasal Congestion

Yes No

Fatigue

Yes No

Cough

Yes No

Fever

Yes No

Sore Throat

Yes No

Chills

Yes No

Shortness of Breath

Yes No

Loss of Appetite

Yes No

Bluish Lips or Face

Yes No

Vomiting

Yes No

Runny Nose

Yes No

Body Aches

Yes No

Pink Eye - Conjunctivitis

Yes No

Loss of Taste or Smell

Yes No

Have you or anyone in your family or coworkers been exposed to COVID-19?

Yes No

Have you been ill with COVID-19?

Yes No

Have you been tested for COVID-19?

Yes No

If yes:

Date

Result

Have you received the COVID-19 Vaccine?

Yes No

Signed

Date

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