John Leung, MD: Have You Brought With You The Following?
John Leung, MD: Have You Brought With You The Following?
John Leung, MD: Have You Brought With You The Following?
John Leung, MD
Boston Food Allergy Center DOB:
65 Harrison Avenue, Suite 201
Boston, Massachusetts 02111
Tel: (617) 804-6767 Fax: (877) 726-8492
Put your name and DOB in the right upper corner of each page
Original and PHOTOCOPY OF (there is a surcharge of $1/page of photocopy service at the clinic)
o Government-issued photo identification, such as a valid passport or driver’s license.
o Relevant medical records (must be in English)
o Vaccination or immunization record (must be in English)
o Proof of prior treatment for TB or other infectious disease(s), if any
Medical insurance card, if any (may cover some of the tests required)
Payment (money order or cash). No personal check or credit card.
Sign & date every page of this document
PATIENT INFORMATION:
Current medications
Medical History
YES NO YES NO
Substance abuse DIABETES
ASTHMA REFLUX/HIATAL HERNIA
TUBERCULOSIS GALLBLADDER DISEASE
HEART PROBLEMS HEPATITIS/JAUDICE/LIVER DISEASE
HYPERTENSION COLITIS/CROHN’S DISEASE
THYROID DISEASE CANCER
STROKE MENTAL DISORDER
SEXUALLY TRANSMITTED DISEASES DEPRESSION/ANXIETY
HIV/AIDS SEIZURE/EPILEPSY
PHYSICAL IMPAIRMENT OTHERS
Please sign and date here to certify the above information is true: _________________ ( / /2016)
Fill out as much as Date received Date received Date received Date received
you can (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy)
DT/DTap/DTP
Td/Tdap
MMR 1st dose 2nd dose
Varicella 1st dose 2nd dose
Influenza (most recent)
Our goal is to complete your i693 accurately and effectively within 1 week, while keeping your cost to the minimum.
By signing below, you indicated that you understand:
10. Recommendations will be made for lab work. Applicants have the option to get lab samples collected in our
clinic for additional fee, or have lab done directly at nearby Quest Diagnostics to avoid the handling fee
11. The immigration medical exam is intended to be a “snapshot” of the applicant’s medical status. Therefore, the
chest X-ray and lab results should be closely related in time to the physical examination. While there is no
defined period of time during which a chest X-ray or lab work is “valid,” we STRONGLY advise that you obtain lab
work and other i693 related studies AFTER your first visit with us. We will tell you exactly what studies you need
and work with your local lab to order them if you prefer obtaining them locally. Results usually available in 72
hours, dependent on your labs. If lab work were obtained from lab other than Quest Diagnostics, applicants are
responsible of obtaining and sending us the report. We are not responsible for obtaining your outside records.
Please sign and date here to certify the above information is true: _________________ ( / /2016)