People First Urgent & Primary Care

I-693 Immigration Physical — Patient Intake

Please complete every field exactly as it should appear on your I-693 form. Double check spelling of your name, dates, and ID numbers before submitting.

Visit Information

Date

Check-in Time

Patient Name

First Name

Middle Name

Last Name

Address

Street Address

City

State

Zip

Contact & Demographics

Email

Phone

Date of Birth

Primary Race

Gender

Male Female

Birth & Identification

Country of Birth

City of Birth

USCIS or A # (if known)

Passport Country & #

ID Issuing State & ID #

Vaccines Received (with proof available)

Tetanus Polio Varicella Pneumococcal Flu MMR Hepatitis B COVID

Check only vaccines you have received AND have documentation for today.

Tests (with proof available)

TB Syphilis Chlamydia Gonorrhea

Check only tests you have proof/results for today.

Visit Information

Date

Check-in Time

Patient Name

First

Middle

Last

Address

Street

City

State

Zip

Contact & Demographics

Email

Phone

Date of Birth

Gender

Primary Race

Birth & Identification

Country of Birth

City of Birth

USCIS or A #

Passport Country & #

ID Issuing State & ID #

Vaccines Received (proof available)

Tests (proof available)