Form I-693 - Report Of Medical Examination And Vaccination Record Page 10
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13Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number (if any)
A-
►
Part 7. Civil Surgeon Worksheet (continued)
B.
Address
Street Number and Name
Apt.
Ste.
Flr.
Number
City or Town
State
ZIP Code
C.
Date of Referral (mm/dd/yyyy)
D.
Remarks: (Include the name of medical condition and the reasons for referral. If you need extra space to complete this
section, use the space provided in Part 10. Additional Information.
Part 8. Referral Evaluation (To be completed by the health department or other doctor performing the
referral evaluation)
The applicant identified on this Form I-693 was referred to me by the civil surgeon named in Part 6. of this Form I-693. I have
provided appropriate evaluation/treatment, having made every reasonable effort to verify that the person whom I have evaluated/
treated is the person identified in Part 1.
1.
Evaluating Physician or Health Department's Full Name
A.
Family Name (Last Name)
Given Name (First Name)
Middle Name
B.
Health Department 's Name
2.
Address
Street Number and Name
Apt.
Ste.
Flr.
Number
City or Town
State
ZIP Code
3.
Signature of Health Department Individual or Other Doctor Performing Referral Evaluation
Signature
Date Signed (mm/dd/yyyy)
4.
Name of Medical Practice or Health Department
5.
Daytime Telephone Number
NOTE: If you need extra space to complete this section, use the space provided in Part 10. Additional Information.
Form I-693 10/19/17 N
Page 10 of 13
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