I-693 Immigration Physical Registration Form

I-693 Immigration Physical Registration Form
Please fill out this secure form accurately.

The information below must match the information you provided to USCIS.
Date of Physical/Appointment: *

Month Day Year
Date
Last Name *
First Name *
Middle Name *
Address *

Address

Street Address Line 2

City

Zip
Date of Birth: *

Month Day Year
Date
Gender: *
Country of Birth: *
City of Birth: *
A-Number (if any)
Alien Registration Number
USCIS Number (if any)
Can you read English? *
Mobile Number: *
The best phone number to reach you
Daytime Number:
Email *
example@example.com
Form of ID used to complete this form *
Document ID Number *
Authorization

I give consent for treatment(s), physical examination(s), and consultation(s) by Dr. Patel. I give my permission for Alpha Medical Clinic and its staff to leave any medical/lab information for me at the phone numbers and email provided by me on this form. You acknowledge that you have been advised of the risk of transmission of this information, understand that this is not a secure format, acknowledge that this information may be seen by a third unauthorized party and take full responsibility of the possible security breach.
Signature *

Please sign using your mouse or finger. This signature is legally binding. Clear
Attachments
Please attach a copy of the following records (bring all original documents to your appointment).
Driver's License

Choose Photo or File

Cancel of
Passport

Choose Photo or File

Cancel of
USCIS issued ID (Green Card, Work Permit/Authorization)

Choose Photo or File

Cancel of
Vaccine Records

Choose Photo or File

Cancel of
Should be Empty:

I-693 Immigration Physical Registration Form

Attachments