Oakton Health Center

Address

4860 Oakton St, Skokie, IL 60077

Mail Us

info@OaktonHealthCenter.com

Call Us

847-329-0470

About Immigration exam

Immigration exam Appointment

IMMIGRATION EXAM BLOG

Patient Portal

News Posts

IMMIGRATION INTAKE FORM

Immigration Medical Exam Intake Form

Patient Intake Form for Immigration Medical Exams

Please complete this form after scheduling your appointment.

Patient Information

First Name *

Middle Name

Last Name *

Date of Birth *

Age (as of today)

Phone *

Email *

Address *

City *

State *

ZIP *

Country *

Gender *

Immigration Information

ID Type *

ID Number *

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

Country of Birth

City/Town/Village of Birth

How did you hear about us?

Do you have vaccination records?

Consent

I confirm that the information I provided is true to the best of my knowledge______________________. * I confirm that the form was given me for corrections______________________. * I checked the form and no mistakes were made_______________________. * I understand that additional charges might be applied if I will return the form for correction after the envelope will be sealed______________________. *

Thank you. Your intake form was submitted successfully.

Sorry, there was a problem sending the form.

Oakton Health Center

Address

Mail Us

Call Us

Immigration Medical Exam Intake Form

Patient Intake Form for Immigration Medical Exams

Patient Information

Immigration Information

Consent

Oakton Health Center

Quick Links

clinic Hours

Monday

tuesday – Friday

Saturday

Sunday

Newsletter