Name:

John Leung, MD
Boston Food Allergy Center DOB:
65 Harrison Avenue, Suite 201
Boston, Massachusetts 02111
Tel: (617) 804-6767 Fax: (877) 726-8492

CIVIL SURGEON PATIENT INTAKE FORM

Have you brought with you the following?

 Put your name and DOB in the right upper corner of each page
 Original and PHOTOCOPY OF (there is a surcharge of $1/page of photocopy service at the clinic)
o Government-issued photo identification, such as a valid passport or driver’s license.
o Relevant medical records (must be in English)
o Vaccination or immunization record (must be in English)
o Proof of prior treatment for TB or other infectious disease(s), if any
 Medical insurance card, if any (may cover some of the tests required)
 Payment (money order or cash). No personal check or credit card.
 Sign & date every page of this document

PATIENT INFORMATION:

Last name Insurance carrier:

First name
Middle name Pharmacy address:
Cell phone
Email Home address:
Date of birth

Current medications

Circle the symptoms if you have any

General symptoms:
Fever, swollen glands, change in vision,
hearing loss, sore throat, runny nose, skin
changes, joint/muscle pain, oral/genital
sores, rash, change in weight, change in
appetite
Neurological: Genitourinary:
Headaches, weakness, loss of sensation, Burning sensation while urinating, blood
numbness, falling, dizziness, depression, in urine, genital discharge, genital itching
anxiety

Heart and Lungs: Abdominal: Other:

Chest pain, irregular heartbeat, cough, Nausea, vomiting, jaundice, abdominal pain,
sputum, blood in sputum, wheezing, heartburn, difficulty swallowing, diarrhea,
shortness of breath, abnormal chest x-ray constipation, bloody stools

Medical History
YES NO YES NO
Substance abuse DIABETES
ASTHMA REFLUX/HIATAL HERNIA
TUBERCULOSIS GALLBLADDER DISEASE
HEART PROBLEMS HEPATITIS/JAUDICE/LIVER DISEASE
HYPERTENSION COLITIS/CROHN’S DISEASE
THYROID DISEASE CANCER
STROKE MENTAL DISORDER
SEXUALLY TRANSMITTED DISEASES DEPRESSION/ANXIETY
HIV/AIDS SEIZURE/EPILEPSY
PHYSICAL IMPAIRMENT OTHERS

Please sign and date here to certify the above information is true: _________________ ( / /2016)

Civil surgeon intake form updated on 1-14-2017 JL

 Name:
John Leung, MD
Boston Food Allergy Center DOB:
65 Harrison Avenue, Suite 201
Boston, Massachusetts 02111
Tel: (617) 804-6767 Fax: (877) 726-8492

Fill out as much as Date received Date received Date received Date received
you can (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy)
DT/DTap/DTP
Td/Tdap
MMR 1st dose 2nd dose
Varicella 1st dose 2nd dose
Influenza (most recent)

Our goal is to complete your i693 accurately and effectively within 1 week, while keeping your cost to the minimum.
By signing below, you indicated that you understand:

1. Payment is non-fundable and upfront. Cash or money order only.

2. Please bring your own copies of all necessary documents (see p.1). The application fee does not cover
photocopying services. If you prefer, we can make photocopy for you with a surcharge of $1/page.
3. First visit usually 45 minutes, but can be up to 1.5 hr.
4. It usually takes 1-2 visits to our clinic to complete the form
5. If you do not obtain recommended vaccines or blood work within 15 business days after your first visit, we
will close your file and payment is non-refundable. There is a $100 fee to re-open your file.
6. Your paperwork is usually ready within 3 business days after all the necessary requirements are fulfilled.
7. On the day of picking up your completed i693 form, the visit may take up to 45 minutes (we have a rigorous
verification process in place to ensure accuracy, 2 trained staff will independently review and verify your
completed form).
8. Your fee include a digital PDF copy of your completed i693 form. Additional hard copy is available for $5 each.
9. Recommendations will be made regarding what vaccines need to be administrated to complete the application,
per CDC guidelines. Applicants have the option to receive the vaccine in the clinic for additional fees or receive
them directly at nearby CVS or Walgreen

10. Recommendations will be made for lab work. Applicants have the option to get lab samples collected in our
clinic for additional fee, or have lab done directly at nearby Quest Diagnostics to avoid the handling fee

11. The immigration medical exam is intended to be a “snapshot” of the applicant’s medical status. Therefore, the
chest X-ray and lab results should be closely related in time to the physical examination. While there is no
defined period of time during which a chest X-ray or lab work is “valid,” we STRONGLY advise that you obtain lab
work and other i693 related studies AFTER your first visit with us. We will tell you exactly what studies you need
and work with your local lab to order them if you prefer obtaining them locally. Results usually available in 72
hours, dependent on your labs. If lab work were obtained from lab other than Quest Diagnostics, applicants are
responsible of obtaining and sending us the report. We are not responsible for obtaining your outside records.

Please sign and date here to certify the above information is true: _________________ ( / /2016)

Civil surgeon intake form updated on 1-14-2017 JL