Website Immigration Questionnaire

Freedom Allergy l Allergy Sinus and Cough Center 115 Genevieve Court, Peachtree City, GA 30269 l P: 678 400 6650 I F: 678 669 2401

Please correct the errors described below.

PATIENT INFORMATION FOR I-693 APPLICATION

First Name

Last Name

Middle Name

Date of Appointment

Date of Birth

Gender

Male Female

Street Address

City

State

Zip Code

Phone Number

Email address

INTERPRETER’S INFORMATION (IF ACCOMPANYING APPLICANT AT INTERVIEW):

First and Last Name

Complete Mailing Address

Phone Number and Email

PROVIDE BOTH COUNTRY OF BIRTH AND CITY/PLACE OF BIRTH

Country

City/Town

ALIEN REGISTRATION NUMBER A

USCIS Online Account Number (if any)

PROVIDE ALL INFORMATON FOR ONE OF THE THREE ITEMS BELOW FOR OFFICIAL IDENTIFICATION:

(1) DRIVER’S LICENSE NUMBER, STATE, and EXPIRATION DATE

(2) PASSPORT NUMBER, COUNTRY, and EXPIRATION DATE

(3) IDENTIFICATION NUMBER, STATE, and EXPIRATION DATE

MEDICAL HISTORY & CURRENT MEDICATIONS

HISTORY OF POSITIVE PPD (TB/Tuberculosis) Screening

Yes No Unsure

ARE YOU PREGNANT

Yes No

HAVE YOU HAD CHICKEN POX

Yes No Had Vaccine

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