Home
About Immigration Medical Exam
Expect During Your Exam
FAQ’s Virtual Physical

Home
About Immigration Medical Exam
Expect During Your Exam
FAQ’s Virtual Physical

Phone

301-984-9009

Fax

301-984-3042

Schedule Today

Home
About Immigration Medical Exam
Expect During Your Exam
FAQ’s Virtual Physical

Home
About Immigration Medical Exam
Expect During Your Exam
FAQ’s Virtual Physical

Report of Immigration Medical Examination and Vaccination Record

Part 1: Information About You (To be completed by the person requesting a medical examination, NOT the civil surgeon.)

Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

GenderMaleFemale

Date of birth

City/Town/Village of Birth

Country of Birth

Alien Registration Number (A-Number) (if any)

USCIS Online Account Number (if any)

Part 2. Applicant's Statement, Contact Information, Certification, and Signature

Applicant's Contact Information

Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).

Applicant's Mobile Telephone Number (if any)

Applicant's Email Address (if any)

Form of Identification Presented by Applicant (for example, passport or driver’s license)

Document Identification Number

CLIENT VACCINATION HISTORY

MMR

MMRYesNoNot sure

Date

Note

Flu Shot

Flu ShotYesNoNot sure

Date

Note

Covid

CovidYesNoNot sure

Date

Note

Varicella

VaricellaYesNoNot sure

Date

Note

Td/Tdap

Td/TdapYesNoNot sure

Date

Note

Tuberculosis ( blood test)

Tuberculosis ( blood test)YesNoNot sure

Date

Note

Syphilis (blood test)

Syphilis (blood test)YesNoNot sure

Date

Note

Gonorrhea (blood test)

Gonorrhea (blood test)YesNoNot sure

Date

Note

Hepatitis B

Hepatitis BYesNoNot sure

Date

Note

Polio Vaccination

Polio VaccinationYesNoNot sure

Date

Note

Contact Info

Phone: 301-984-9009
Fax: 301-984-3042
Email: info@virtualphysical.com

Location: 11400 Rockville Pike Suite 105, North Bethesda, MD 20852
Hours: Monday to Friday, 9 AM – 5 PM

Phone

Fax

Report of Immigration Medical Examination and Vaccination Record

Part 1: Information About You (To be completed by the person requesting a medical examination, NOT the civil surgeon.)

Part 2. Applicant's Statement, Contact Information, Certification, and Signature

Contact Info

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