Patient Personal and Medical Information.

Please note that all the information submitted in this form will remain confidential in accordance with HIPAA law. Also, by submitting this form you are certifying that all your information hereby submitted is accurate and truthful. Also note that the information submitted in this form will be used to fill the I-693 Form (Report of Medical Examination and Vaccination Recod) and falls under Federal jurisdiction of the U.S. Government.

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