Immigration Medical Examination Questionnaire

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? Traveler's and short term-health insurance is not accepted

Yes No

Do you have vaccination records (other than COVID-19)?

Yes No

Documents (Not in Clinic)

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

Add file

Please upload a file

Do you have health insurance coverage? Traveler's and short term-health insurance is not accepted

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 (other than COVID-19) ?

Yes No

Please upload your vaccination records (other than COVID-19) Include the cover page of any vaccine cards

Add file

Please upload a file

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 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 and/or individual handling your case?

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

Applicants ages 6 months and older must fulfill the USCIS COVID-19 vaccine requirement before the Civil Surgeon can sign their I-693 Report of Medical Exam and Vaccination Record. For those who have not already completed a primary series of COVID-19 monovalent vaccination, this requirement can be fulfilled with a single dose of an age-appropriate bivalent mRNA vaccine.

If an applicant refuses to complete the COVID-19 vaccine requirement, the Civil Surgeon must indicate on Form I-693 that the applicant does not meet immunization requirements (unless s/he fulfills the criteria for a medical exemption). This notation would result in the applicant being considered "medically inadmissible" which is grounds for the denial of their adjustment of status application.

Notwithstanding, individuals who refuse all vaccinations on moral and/or religious grounds may file a waiver of inadmissibility at a cost of $930 using USCIS Form I-601. If you intend to file this waiver, please notify a member of the office staff prior to your appointment. Note that the USCIS officer reviewing your case will use their discretionary authority in deciding whether or not to approve a waiver of inadmissibility.

Have you already completed a primary COVID-19 vaccine series?

Yes No

Have you already received at least one dose of COVID-19 vaccine?

Yes No

Please upload your proof of COVID-19 vaccination Include the cover page of any vaccine cards

Add file

Please upload a file

Which brand of COVID-19 vaccine would you prefer to receive ?

Moderna bivalent (6+ months old)

One dose (no second dose)

It is not age applicable

I'm less than 6 months old

I refuse the COVID-19 vaccine

I'm applying for a waiver (I-601)

I have a medical contraindication

I'll provide an official doctor's note

Medical/Social Information

Do you have any allergies to medication, vaccines, food and/or the environment?

Yes No

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

Do you have any chronic medical conditions?

Yes No

Please list any medical condition(s) you have and the medication(s) used to treat them. For example: Diabetes - metformin (daily); asthma - Ventolin inhaler (as needed); hypothroidism - Synthroid (daily)

Do any of these conditions interfere with either the ability to care for yourself or to attend school/work?

Yes No

Are you currently pregnant?

Yes No

Vaccination Consent

I consent to receive any vaccines that United States Citizenship and Immigration Services (USCIS) requires to be considered medically admissible for the adjustment of status ("green card") application. If I feel unwell or am running a fever (100.4° F/ 38° C) on the day of my appointment, I will notify a medical staff member prior to receiving any vaccines. I agree to hold harmless Gateway Medical, its staff and the civil surgeon overseeing my medical examination for any adverse reactions which may occur because of vaccines administered to me at the clinic.

Yes (applies to all vaccines required by USCIS for adjustment of status applications) No (vaccines will not be administered unless a consent form is completed at the office)

IMPORTANT: Prior to your appointment, please use the website link provided below to learn about the potential contraindications and common adverse reactions associated with any vaccines which you will receive here at Gateway Medical: https://www.cdc.gov/vaccines/hcp/vis/current-vis.html . If you have a contraindication to receiving any vaccine(s), please let the medical staff know during your appointment.

Vaccine Pricing

The fee charged for immigration medical examination does NOT include the price of vaccines. Most employer-sponsored or Marketplace (Obamacare) health insurances cover the cost of vaccines in full. If you are uninsured or your particular insurance policy does not cover vaccines, we can provide them at our clinic for an additional fee. Listed below are the prices for the most commonly USCIS-required vaccines :

Seasonal Influenza*- $40
Tdap - $60
Hepatitis B** - $80
MMR** - $100
Pneumonia 23 - $120
Varicella** - $160

*Only required during flu season (October-March)
**Only required if you are not immune to the disease(s)

USCIS vaccine requirements are based on age group.
Not all of the listed vaccines will be relevant to your case.

If you are unable to afford your vaccines and would like apply for patient financial assistance, please provide our staff with proof of your household income so that we may determine your program eligibility.

Examples of suitable income proof include:
Form W-2 (employee), Form 1099 (contractor), Form 1040 (yearly taxes), or paystubs (30 days)

Passport Photos

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

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

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

All green card applicants, even those without a social security number, are eligible to sign up for major medical health insurance via The Healthcare Marketplace (aka Obamacare) within 60 days of their arrival in the United States. They are also eligible to enroll within 60 days of their marriage or the birth of their child. Outside of those special circumstances, the only opportunity to sign up for this individual health insurance is during the national open enrollment period which runs each year from November to January.

Obamacare offers all eligible individuals health insurance regardless of their previous medical history and is able to offer even lower monthly rates for individuals who currently have low to moderate income. The plans are offered by private insurance companies but must adhere to certain standards such as offering coverage for preventative care, hospitalization, medication, primary care visits, specialist consultations, urgent care, imaging studies, physical therapy, laboratory testing, pregnancy, surgery, and mental health.

Would you be interested in receiving more information from our office regarding Obamacare enrollment?

Yes please No thank you

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 two years from the date of the civil surgeon's signature. Do not open this envelope or your paperwork will be considered invalid. Per USCIS guidelines, we will also provide you with a photocopy of your Form I-693. If you need to obtain another copy your medical records 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 negligence on the part of our office.

Health Insurance

Although our office does not itself hold any health insurance contracts, we will forward your insurance information to our laboratory, BioReference, and/or our vaccine supplier, VaxCare, so that they can bill your health insurance company. Our clinic and 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 preventative 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)

Documents (Not in Clinic)

Personal Information

Immigration Information

Interpreter Information

COVID-19 Vaccination Requirement

Medical/Social Information

Vaccination Consent

Vaccine Pricing

Passport Photos

Health Insurance

Office Policies

Gateway Immigration Medical Exams