Dr. W. P. Ciszak Medical Services Inc.
IMMIGRATION MEDICAL EXAMINATIONS IN VANCOUVER
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Registration form for Australian medical exam

Before we can give you an appointment for your medical exam we must receive your registration.

We wil use this information to validate your case and then prepare your eMedical file. Your file will be ready for you when you come in for your appointment.

A separate form is required for each family member.

Is this secure?
Yes. The information you submit is sent to our office by encrypted email. It is not stored on the server so it cannot be hacked.

 

Please take extreme care to avoid errors in filling the form!

Application type
Please select type
Given names (First name) RequiredFull given names required.
FAMILY NAME (Last name) RequiredFull last name required
Gender Please select one option
Date of Birth RequiredFormat dd/mm/yyyy Date format: dd/mm/yyyy
Country of birth RequiredMinimum number of characters not met
Address - Street RequiredDoes not look valid
Address - City City is missingDoes not look valid.
Address - Prov or State A value is requiredTwo characters required.Two letters only.
Address - Postal Code Postal code or zipcode requiredDoes not look valid
Telephone Phone number requiredInvalid format - use 0000000000Must have 10 digitsMust have 10 digits.
Email RequiredEnter Email address or "none".Invalid format
Passport number ID number requiredDoes not look valid
Passport country Issuing country?Does not look valid
Passport issue date RequiredFormat dd/mm/yyyy.Date format: dd/mm/yyyy
Passport expiry date RequiredFormat dd/mm/yyyyDate format: dd/mm/yyyy
HAPID number
   
How did you hear of us? Select


I agree to the Terms and Conditions
Check the box if you agree

STOP!
Please double-check your entries before submitting!
Errors will be difficult to correct after your file is created.

Application type

Please select a valid item

Given names (First name)

Required

Full given names required.

FAMILY NAME (Last name)

Required

Full last name required

Gender

Please select one option

Date of Birth

Required

Format dd/mm/yyyy

Date format: dd/mm/yyyy

Country of birth

Required

Minimum number of characters not met

Address
- Street

Required

Does not look valid

Address - City

City is missing

Does not look valid.

Address - Prov or State

A value is required
Two characters required.
Two letters only.

Address - Postal Code

Postal code or zipcode required
Does not look valid

Telephone

Phone number required
Invalid format - use 0000000000
Must have 10 digits

Must have 10 digits.

Email

Required
Enter Email address or "none".Invalid format

Passport number

ID number required
Does not look valid
Passport country

Issuing country?

Does not look valid

Passport issue date

Required

Format dd/mm/yyyy.

Date format: dd/mm/yyyy

Passport expiry date

Required

Format dd/mm/yyyy

Date format: dd/mm/yyyy

HAPID number
 
 
How did you hear of us?

Select one


I agree to the Terms and Conditions
Check the box if you agree

STOP!
Please double-check your entries before submitting! Errors will be difficult to correct after your file is created.

Please use only English characters. International letters and accents are not recognized by the eMedical system.

Health Assessment Portal ID

You must have received this number when you filed your application.

Your own personal email, not work email, lawyer's email or friend's email. This may be used for confidential information.

Canadian or US number only. Local phone number preferred. This is needed to contact you if additional tests are required or other problems occur,

Format: 10 digits without hyphens or spaces.

Local address is preferred, even if it is not permanent.

For all dates on this form, be sure to use this format: dd/mm/yyyy
(numeric DAY, MONTH and full YEAR separated by slashes)

Immigration type that you are applying for, NOT your current status.

Family Class is for a sponsored family member, spouse or partner,

Student, Visitor, Worker are categories for a temporary stay in Canada.

If you are applying for permanent immigration and do not fit the above categories, choose IMMIGRANT.

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