Immigration Medical Examination Questionnaire

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

Oakland Park Miami

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 other insurance which is not compliant with the Affordable Care Act (e.g. US Health Group and International Medical Group)

Yes No

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

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 (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

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.

On what date did you arrive in the United States? (Use the most recent date of entry)

If you do not know the exact date, please provide at least the month and year of entry.

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 and/or individual 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

Starting November 29th, 2023 all adjustment of status applicants 6 months of age and older are required to receive one dose of the most updated version of the COVID-19 vaccine (currently the 2023-2024 formulation). Individuals who previously completed a monovalent and/or bivalent COVID-19 vaccine series are not considered up to date unless they have received the current COVID-19 booster.

If an applicant refuses to received an approved COVID-19 vaccine, 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 received one dose of the 2023-2024 formulation of the COVID-19 vaccine?? Note: Do not mark "yes" if you have only received the monovalent and/or bivalent COVID-19 vaccines.

Yes No

Present your COVID-19 vaccination proof to our front office staff

How do you want to fulfill the COVID-19 vaccination requirement?

I'll get vaccinated at the pharmacy

One dose (no second dose)

I'll get vaccinated at Gateway Medical

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

COVID-19 Vaccination Requirement

Have you already received one dose of the 2023-2024 formulation of the COVID-19 vaccine? Note: Do not mark "yes" if you have only received the monovalent and/or bivalent COVID-19 vaccines.

Yes No

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

Add file

Please upload a file

How do you want to fulfill the COVID-19 vaccination requirement?

I'll get vaccinated at the pharmacy

One dose (no second dose)

I'll get vaccinated at Gateway Medical

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 at Gateway Medical any vaccines that United States Citizenship and Immigration Services (USCIS) requires in order to be considered medically admissible for the adjustment of status process. 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 No

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
Polio** - $50
Tdap - $60
Hepatitis B** - $80
MMR** - $100
Pneumonia 23 - $130
Varicella** - $180

*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.

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 insurance via The Healthcare Marketplace. Although the annual open enrollment period is from November to January, individuals can sign up during other months if their income is below 150% of the Federal Poverty Line or if they experienced a qualifying life event within the last 60 days such as moving to the United States, getting married, or having a child.

The Healthcare Marketplace provides affordable insurance regardless of an individual's pre-existing medical conditions and includes the following medical benefits: Preventive care, hospitalization, medication, primary care visits, specialist consultation, urgent care, imaging studies, physical therapy, laboratory testing, pregnancy care (if applicable), surgery, and mental health.

Would you be interested in learning more about US health insurance from a member of our staff?

Yes please No thank you

Fill out the following form prior to speaking with our insurance specialist: https://hushforms.com/insure

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)

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

Present your COVID-19 vaccination proof to our front office staff

COVID-19 Vaccination Requirement

Medical/Social Information

Vaccination Consent

Vaccine Pricing

Passport Photos

Health Insurance

Office Policies

Gateway Immigration Medical