Immigrant Visa Medical Informatioin by tyl10582


									                       Immigrant Visa Medical Information
                              American Consulate General Chennai
                                                 220, Mount Road
                                                 Chennai 600 006
Date of initial laboratory exam:

Date of physical examination:

Date of follow-up laboratory tests:

Title:   Dr. / Mr. / Mrs. / Ms. / Mast. / Miss


Address:                                                                       Please attach
                                                                             photograph here.

Place of birth:

Date of birth:    ______ / ______ / ______
                  Day      Month Year

Passport Number:

                                                            Signature of the Lab Technlogist

__________________________________                          __________________________________
Signature of the Applicant                                  Signature of the Radiographer

The person named above has undergone the                    The person named above has been medically
laboratory exams at Lister Laboratory and the               examined by me and my report is submitted on
case reviewed by me.                                        the attached form OF-157.

__________________________________                          __________________________________
Signature of the Lab Physician                              Signature of the Examining Physician

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