Immigration Medical Examination Questionnaire

If "Other", please describe below:

At which clinic location is your appointment scheduled to take place?

Aventura Oakland Park West Palm Beach

Do you already have an appointment to see the immigration doctor for a physical exam?

Yes No

On what date are you scheduled to see the immigration doctor?

How do you wish to receive your Form I-693 once it's complete? If you choose a mailing option, we will use USPS priority mail with tracking

I will pick it up in-person Mail it to my home ($20) Mail it to my attorney ($20)

Are you inside the clinic right now?

Yes No

Present your identification document, insurance card (if any) and vaccine records (if any) to our front office staff prior to filling out this online form.

Documents (In Clinic)

Do you have health insurance coverage? We do not work with traveler's health insurance, short term health insurance, or any insurance policies which are not compliant with the Affordable Care Act (e.g. US Health Group, IMG, and VUMI)

Yes No

Do you have vaccination records?

Yes No

Do you have a discount coupon?

Yes No

Present your coupon to a front office staff member. Please note: Your referring legal provider must be an active Gateway Medical e-mail subscriber in order for your coupon to be valid.

Documents (Not in Clinic)

Please upload your identification document Driver's License, National Identity Card, or Passport

Add file

Please upload a file

Yes No

Please upload your health insurance card We need both the front and back sides to verify coverage

Add file

Please upload a file

Do you have vaccination records?

Yes No

Please upload your vaccination records. Include the cover page of any vaccine cards

Add file

Please upload a file

Do you have a discount coupon?

Yes No

Please upload an image of your coupon Include the back side (if applicable)

Add file

Please upload a file

Bring your coupon to the appointment and present it to a front office staff member. Please note: Your referring legal provider must be an active Gateway Medical e-mail subscriber in order for your coupon to be valid.

Personal Information

Please fill in all information exactly as you want it to appear on your USCIS Form I-693 Medical Exam

First Name

Middle Name

Last Name

City of Birth (NOT current city)

Country of Birth

Date of Birth (ex: 24 June 1982)

E-mail Address

Cell Phone Number

Daytime Phone Number

Home Address

Apt #

Current City

Zip Code

Immigration Information

What is your nationality? (Usually corresponds to the country that issued your passport)

If you have multiple nationalities, please list the one which you most strongly identify with.

Did you arrive to the USA in the last 60 days?

Yes No

On what exact date did you arrive in the USA?

In what year did you arrive in the United States?

In which country did you reside prior to arriving in the United States?

What is your alien identification number, if any? (For example: 219-345-746)

This is a nine digit number that USCIS assigns to your adjustment of status application. It appears on most correspondence sent to you by USCIS and starts with the letter "A". For example: A219-304-659. If you have an employment authorization card, it is listed as "USCIS #" without the letter A. For example: 219-304-659.

What is your USCIS online account number? (If any)

Is there a law firm, attorney, paralegal or document preparer handling your immigration case?

Yes No

What is the name of the office handling your case?

What is the name of the professional handling your case?

Is this your first immigration-related medical exam?

Yes No

Which immigration exam(s) have you previously completed?

Immigration Medical Exam (inside the USA)

Panel Physician Exam (outside of the USA)

Refugee Exam (County Health Department)

Other / Something Else Not Listed Here

If you chose "Other", please provide details below:

Interpreter Information

Are you able to independently read, understand and respond in English?

Yes No

You require an interpreter for your medical examination. Please list your interpreter's information below:

Language of Interpretation

Interpreter's Relationship to You

Interpreter's First Name

Interpreter's Last Name

Interpreter's Daytime Phone Number

Interpreter's Cell Phone Number

Interpreter's Email Address

COVID-19 Vaccination Requirement

On January 22, 2025, USCIS issued a statement reversing its previous requirement that green card applicants must be up to date on their COVID-19 vaccination to be considered medically admissible.

Effective immediately, USCIS will not deny any adjustment of status application based on the applicant’s failure to present documentation that they received the COVID-19 vaccination.

For applicants who have received one more doses of COVID-19 vaccine in the past, our office will continue to document those doses on their USCIS Form I-693 vaccination record.

Any applicants who would like to be better protected against COVID-19 are welcome to receive a booster dose of the 2024-2025 COVID-19 vaccine at our clinic. The cost is covered 100% by most insurances.

Do you want to receive a 2024-2025 Moderna COVID-19 booster at our clinic?

Yes, I would like it. No, I do not want it.

Medical History

Do you have any allergies to medication, vaccines, or food?

Yes No

Please list the allergen(s) and the the reaction(s) that it/they cause

Do you have Human Immunodeficiency Virus (HIV)? HIV positive individuals with an undetectable viral load should still mark "Yes"

Yes No

Applicants with HIV are required to undergo a chest x-ray and sputum testing with the health department to rule out tuberculosis infection. The process of culturing sputum samples takes 2-3 months which is significantly longer than the normal turnaround time to complete Form I-693. As a result, we suggest that applicants starting their immigration petition now send in their adjustment of status paperwork without the medical examination in order to avoid processing delays. Applicants who received a Request for Evidence (RFE) in the mail from USCIS requesting that they complete their medical exam immediately should present your RFE letter to a member of our staff so that we can draft a response letter to USCIS requesting an extension to the due date for your Form I-693.

Are you currently immunosuppressed (i.e. have a weakened immune system) ? People who are immunosuppressed have difficulty fighting off infection and diseases.

Yes No

Is your immunosuppression due to a medical condition or a medication? People who are immunosuppressed have difficulty fighting off infection and diseases.

Medical Condition Medication Both

Please list the medical condition(s) you have which result in immunosuppression

Please list the medication(s) you take which result in immunosuppression

Do you have any chronic medical condition(s) that you have not already mentioned?

Yes No

List any chronic medical conditions you have in the space below:

Please have a list of medications available at your appointment

Do any of your medical conditions interfere with either your ability to care for yourself, work or attend school?

Yes No

Are you currently pregnant?

Yes No

Are you actively trying to become pregnant?

Yes No

Text Messaging

In order to expedite communication with clients, our clinic has found it useful to utilize a text messaging platform. If you opt-in, our staff will send text messages and/or images to the phone number we have "on file" which may include any phone number used to call our clinic, the phone number included in the demographics section of this questionnaire, or any phone number provided to our staff as a point of contact for the client. Please be aware that if you opt-in, personal health information (PHI) including but not limited to laboratory results may be communicated through this messaging system.

Do you consent ("opt-in") to the use of text messaging as described above? You may "opt-out: at any time by e-mailing intake@gatewayimmigration.com

Yes No

Examination Costs

To download a PDF containing pricing information, click this link

All clients are charged $208 for their physical examination and completion of USCIS Form I-693.

HAS INSURANCE: Most clients with health insurance can use their policy to cover the costs of laboratory testing and vaccinations. Notwithstanding, clients with short term insurance plans, traveler's insurance, or almost any type of coverage which is non-compliant with Affordable Care Act (ACA) standards will likely NOT be able to use their insurance policy to cover the costs of these additional services. Some common examples of insurance companies offering such policies are VUMI, IMG and US Health Advisors.

NO INSURANCE: Clients without insurance will need to pay for their laboratory testing (children pay $52 each and adults pay $104 each). Uninsured adults must also pay for required vaccinations, the total cost of which depends on the client's age, medical history, prior vaccine records, and immunity test results. Most vaccines are available at our office for a reasonable fee; however, clients may also get vaccinated at a pharmacy, the health department or any other accredited medical provider. Uninsured children ages 0-18 can receive their vaccines for $20/each through the Vaccines for Children (VFC) at our Oakland Park office only.

Passport Photos

USCIS requires that you submit two passport style photos along with each of the following applications:

I-130 (petition for alien relative - marriage based)
I-485 (adjustment of status / green card)
I-765 (employment authorization / work permit)
I-131 (travel document / advance parole)

We have passport photo booth kiosk in the lobby of our Oakland Park clinic. The kiosk is self-service and has been specifically designed to check that your photo meets all USCIS technical criteria prior to printing. A pair of photos costs $14.99 and can be printed out and cut to the appropriate size immediately on site. Please feel free to access this kiosk at your leisure prior to or after your immigration medical examination.

Health Insurance

Healthcare in the United States can be extremely expensive for individuals who do not have insurance.

Most people do not know that anyone who is lawfully present in the US is able to enroll in an individual insurance policy, even before they receive their social security number. If you would like to learn more about your health insurance options in the United States, including plan types and pricing, you can set up an free informational appointment by talking with our front office staff or calling 800-339-9556.

PS: Most health insurance policies cover 100% of vaccination costs. That means that purchasing a policy this month now could save you hundreds of dollars off the total cost of your immigration medical exam.

Office Policies

Legal Relationship

Although civil surgeons are fully licensed medical professionals, an immigration medical exam does NOT constitute engagement in a patient-doctor relationship. The civil surgeon is solely responsible for the documentation of your health status and, when applicable, the treatment of communicable diseases in the manner outlined by the USCIS technical instructions. The civil surgeon bears no responsibility to diagnose or treat health Class B conditions that you are known to have or are diagnosed with at the examination.

Medical Records

Upon completion of the immigration medical exam, we will provide your original Form I-693 in a sealed envelope which will be considered valid by USCIS for an indefinite period of time. If you open this envelope, your paperwork will be considered invalid. Per USCIS guidelines, our office will also provide you with a photocopy of your Form I-693. If you need to obtain another copy at any point in the future, please call our client service line. Additional charges may apply.

Requests for Evidence

If you receive a Request for Evidence (RFE) letter from the USCIS in response to a medical exam completed at our office, please contact us immediately so that we can resolve any deficiencies in your paperwork. Additional charges may apply unless the RFE was due to our office's negligence (per the discretion of the manager on duty).

Billing Insurance

Our office will forward your insurance information to our contracted partners so that they can bill your health insurance company to cover the cost of laboratory testing and/or vaccinations. Neither Gateway nor its staff assume no liability for the outcome of any coverage and/or payment determinations made by your health insurance company. We suggest that you contact your insurance company prior to your visit to find out about your plan's preventive service benefits. If requested, our office will provide you with a complete list of service and diagnosis codes which may assist your insurance company in accurately communicating applicable plan benefits and coverage information.

Adverse Reactions

If you feel that you are experiencing a serious allergic reaction to a vaccination which was administered in the office, we ask that you contact us immediately at 800-339-9556 . If you are too far away to visit us in-person and/or if the doctor is not available, please seek medical attention at a nearby urgent care clinic.

Your information will be encrypted.

Immigration Medical Examination Questionnaire

Present your identification document, insurance card (if any) and vaccine records (if any) to our front office staff prior to filling out this online form.

Documents (In Clinic)

Present your coupon to a front office staff member. Please note: Your referring legal provider must be an active Gateway Medical e-mail subscriber in order for your coupon to be valid.

Documents (Not in Clinic)

Bring your coupon to the appointment and present it to a front office staff member. Please note: Your referring legal provider must be an active Gateway Medical e-mail subscriber in order for your coupon to be valid.

Personal Information

Immigration Information

Interpreter Information

COVID-19 Vaccination Requirement

Medical History

Text Messaging

Examination Costs

Passport Photos

Health Insurance

Office Policies

Gateway Immigration Medical