Prism Immigrant Medical Center - Enrollment Form-One printable pdf download

Prism Immigrant Medical Center - Enrollment Form-One

AAA Prism Immigrant Medical Center

Date

Medical Record No.

ENROLLMENT FORM-ONE

Family Name [ Last Name ]

Given Name [ First Name]

Full Middle Name

Home Address: Street Number and Name

Apt No.

Male

Female

City

State

Zip code

Phone #

D.O.B. [mm/dd/yyyy

Place Of Birth City/State

Country Of Birth

Apt #

S. S. #

Form Of I.D.- Driver's License or State I.D. or Passport or Consular or School I.D.

I.D. NUMBER

Employment Company Name

Your Position

Email / Website

Legal Representative's Name and Phone no.

Attorney's Email

Your Email Address

Chauffeur's No.if available

Single

Married

I acknowledge having received notice of Hippa Privacy Act.

I have received and reviewed pre and post immigration medical exam instruction sheet.

I authorize medical exam by physician

I authorize to undergo blood screening for Syphilis [ RPR ] / Urine Drug Screen and report abnormal results to authorities

I have been explained in detail about the charges for the exam in detail and have agreed to pay the amount in Check Or Cash

I have also been advised that additional charges nay incur due to abnormal initial screening results.

Additional Vaccinations at extra costs, may be required, if the antibody titers are negative.

I acknowledge the limitations of this medical exam, which is performed as per the guidelines set by USCIS. I'm required to

follow up with my private physician for routine annual check up, preventive investigations and treatments of ongoing

ailments. This medical center or its physicians are neither my advisor or provider of my ongoing or follow up health care needs!

Patient's Or Legal Guardian's Signature

Date:

Prism Immigrant Medical Center - Enrollment Form-One