Fillable Printable Medical Examination Report - California

Medical Examination Report - California

MEDICAL E XAMINATION REPORT

For New Applicants:

1. The Medical Examination may be done in Singapore by any registered General Practitioner (GP). Applicants who are

in their home countries/places of residence may have their Medical Examination and HIV test done in their home

countries/places of residence at any medical clinic licensed to carry out such tests. If HIV testing is done in

Singapore, it may be carried out w ith either rapid or ELISA tests.

For Renewal Applicants:

1. The Medical Examination MUST be done in Singapore by any registered GP. HIV testing may be done with either

rapid or ELISA tests.

Notes for All:

1. This Medical Examination Report is to be completed by a registered doctor and returned to the examinee. The

original copy of the laboratory report for HIV and the X-ray report must be attached to this Medical Examination

Report only if the medical examination and testing is carried out overseas.

2. The laboratory report for HIV and the X-ray report submitted to the Immigration & Checkpoints Authority should be

w ithin THREE MONTHS from the d ate o f the issue of the reports.

I Personal Particulars

1. Name (as in the passport):

2. Sex: M / F 3. Date of Birth : 4. Nationality :

5. Passport No. : 6. FIN No. (if applicable) :

7. Address in Singapore:

II Medical Examination

I certify that the above-named has un dergone a chest x-ra y and the result of his/her ches t X-ray is as indicated (with a [√]):-

Yes No

1. TB (Chest X-ray)*

Any evidence of

active TB detected?

[*Pregnant Women are exempted from Chest X-Ray]

I certify that I have tested the above-named and the result of his/her HIV test is indicated below (with a tick [√]).

Positive Negative/Non-Reactive

2. HIV :

Name of Examinin g Doctor (IN BLOCK LETTERS):

Signature : Clinic’s Stamp & Address:

Date: Telephone Number :

MCR no: _______________ ________

NOTE: For persons screened overseas, the name in the laboratory report for HIV and the X-ray report must be accordi ng to the

name shown in the Passport.

DECLARATION

I, declare that the abov e is not applicable to me as

(

name

)

I have submitted a medical re port** containing the above information to Immigration & Checkpoints Authority / Ministry of

Manpow er*** (n ot more than two years ago) when I was granted the

ass t

)

on valid till .

(dd/mm/yy)(dd/mm/yy)

Signature & Date

** Those who were previously exempted from submitting the X-ray report because of pregnancy are required to submit a X-ray report certified

by a Singapore register ed GP, if you are not pregnant now.

*** Delete where necessary.

WARNING:

IT IS AN OFFENCE UNDER THE IMMIGRATION ACT

TO MAKE ANY FALSE STATEMENT, REPRESENTATION OR DECLARATION

Version 4 (4 Oct 07)