Please fill out this form before your appointment.
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What date is you appointment *

 
Which country are you applying for an immigration medical? *


 
Preferred Title? *


 
Family Name(s) (from identification document)? *

 
Personal Name(s) (from identification document)? *

 
Date of Birth? *

 
Vancouver Island Address? *

 
Phone Number? *

 
Do you have an IME number? *

     
 
Please type your IME number *

 
Category of Application? *


 
Type of ID? *


 
Passport Number? *

 
Date of Issue? *

 
Date of Expiry? *

 
Passport copy certified by IRCC Number? *

 
Date of Issue? *

 
Date of Expiry? *

 
ID Number? *

 
Date of Issue? *

 
Date of Expiry? *

 
Licence Number? *

 
Date of Issue? *

 
Date of Expiry? *

 
UCI number? *

 
Date of Issue? *

 
Date of Expiry? *

 
Registration Number? *

 
Date of Issue? *

 
Do you have a HAP ID or TRN number? *

     
 
Please type the number *

 
Type of ID? *


 
Passport Number? *

 
Date of Issue? *

 
Date of Expiry? *

 
Type of ID? *


 
Passport Number? *

 
Date of Issue? *

 
Date of Expiry? *

 
ID Number? *

 
Date of Issue? *

 
Date of Expiry? *

Thank you for filling out this form.