Canadian Immigration Medical Booking Request Form
Name as it appears on passport
and county of birth
Block capitals please:
1.
Date of Birth: Passport Details
Number:
Start Date:
Expiry Date:
Country of Birth:
2.
Country of
Issue:
Number:
Start Date:
Expiry Date:
Country of Birth:
3.
Country of
Issue:
Number:
Start Date:
Expiry Date:
Country of Birth:
4.
Country of
Issue:
Number:
Start Date:
Expiry Date:
Country of Birth:
5.
Country of
Issue:
Number:
Start Date:
Expiry Date:
Country of Birth:
6.
Country of
Issue:
Number:
Start Date:
Expiry Date:
Country of Birth:
Address:
Post Code:
Daytime Number
Mobile Number
Country of
Issue:
IME Number
Appointment Details: Please indicate how many of each appointment type you require:
Type of Medical
Adult – 15 years and older
£285 (Includes HIV +
Medical, chest xray and bloods
VDRL only)
Child – 11 to 14 years old
£195
Medical and chest xray
Child – 10 years old and younger
£90
Medical only
*Please note additional tests that may be required depending on your medical examination
Are you having an upfront medical? Please tick:
If so please specify the type (ie) Family/Student/Occupational
Yes □
No □
For those attending under the age of 18 please confirm that someone with
parental responsibility is attending the medical examination: Yes □
No □
For more information click here: https://www.gov.uk/parental-rights-responsibilities/what-is-parentalresponsibility
Pre Appointment Checklist:
Tick to confirm:
Have you lodged your visa application?
Have you printed your Health Examination Referral Letter?
Have you printed a Bridge Clinic Immigration Registration Form?
Have you remembered your passport (For everyone having a medical
including babies)? If passport unavailable please advise on 01628 760919
Have you remembered you glasses or contact lenses for sight test?
Significant medical history? Bring relevant reports.
Cancellation policy noted
PLEASE NOW EMAIL THIS FORM TO: immigration@bridge-clinic.com
OR FAX TO: 01628 760915
On receipt of your booking form we will aim to call you back within 24 hours (please
note we are closed at weekends).
Should you have any concerns when completing this form please telephone 01628
760919
FOR OFFICE USE ONLY:
Canada
Date of Appointment
Chest Xray
Time
Medical Time
Confirmed
to Xray
1.
2.
3.
4.
5.
6.
Details entered on Practice Manager:
Confirmed on eMedical:
Credit Card Confirmation (To be taken at the time of booking):
Card Number:
Expiry Date:

Sec No:
Patients are advised that 48 hours notice is required for cancellations otherwise a £55 fee per
person will be levied.