Citizenship and Immigration Canada

Citoyennet et Immigration Canada

PROTECTED WHEN COMPLETED - B

Medical Examination Instructions

These medical instructions are being issued since your application has been processed to the stage where medical examination results are now required. Please read these instructions carefully. IMPORTANT: You are required to undergo the medical examinations within 60 days of the date of this letter. Failure to do so could result in the refusal of your application. The medical examination must be performed by a doctor from the CIC list of Panel Physicians. You cannot choose your family doctor if his or her name is not on this list. See the list of Panel Physicians to find a doctor in your area at: http://www.cic.gc.ca/dmp-md/medical.aspx Once you identify a panel physician in your area, book an appointment for your medical examination. When you schedule your appointment, please ensure that arrangements are made for your chest x-ray and laboratory tests as well. Once your medical has been completed the doctor will forward the medical results to CIC. Any costs related to the medical examination are your responsibility and are payable at the time of the examination. Should your application be refused following the completion of your medical examination these costs will not be refunded. Please bring the following to your appointment: - The attached Medical Report form (IMM1017E) - Proper identification (proof of identity must include at least one government-issued document with photograph and signature, such as a passport or national identity card) - Eye glasses or contact lenses, if worn - Any medical reports or test results that you may have as a result of previous or existing medical conditions - Four recent photographs (photos are not required if the panel physician is listed as eMedical enabled on the CIC website listed above) Note: It is important that you inform the panel physician of any previous or existing medical conditions. Failure to do so will delay the processing of your medical examination.

IMM 1017 E (12-2012) GCMS

Citizenship and Immigration Canada

Citoyennet et Immigration Canada

PROTECTED WHEN COMPLETED - B

MEDICAL REPORT
CLIENT BIODATA AND SUMMARY

Required for all clients. Must be taken within six months of the medical examination.

CLIENT INFORMATION
Family name Given name(s)

LADOC
Date of Birth Address
YYYY - MM - DD

EDWIN
Country of Birth Gender

1963/12/23

Philippines

VILLA CARMELA SUBD POB ILAUD ZARRAGA ILOILO 5004 Philippines

E-mail Address Telephone no.

edwin_ladoc@yahoo.com

+639129234902

IMMIGRATION DETAILS
IMM Type: UCI: Application no.:

Non EDE
91231634 E000157349

IME no:

11369572

*11369572*
B. Significant abnormal history and/or significant abnormal findings present.

IMMIGRATION MEDICAL EXAMINATION GRADING

A. No significant abnormal history or abnormal findings present. Comments:

PANEL PHYSICIAN DECLARATION

Valid identity document (passport/national ID) sighted? Do you have identity concerns? No Yes

If YES, please provide details: No Yes

I confirm that this immigration medical examination and report is a true and accurate record of my findings. Panel Physician name

Panel Physician signature

Panel Physician no.

Date of IME submission

YYYY

MM

DD

IMM 1017 E (12-2012) GCMS