Citizenship and

Immigration Canada

Citoyennet et
Immigration Canada

PROTECTED WHEN COMPLETED - B

Medical Examination Instructions

These medical instructions are being issued since your application has been processed to the stage
where medical examination results are now required. Please read these instructions carefully.
IMPORTANT: You are required to undergo the medical examinations within 30 days of the date of this
letter. Failure to do so could result in the refusal of your application.
The medical examination must be performed by a doctor from the CIC list of Panel Physicians.
You cannot choose your family doctor if his or her name is not on this list. See the list of Panel Physicians to
find a doctor in your area at: http://www.cic.gc.ca/pp-md/pp-list.aspx
Once you identify a panel physician in your area, book an appointment for your medical examination.
When you schedule your appointment, please ensure that arrangements are made for your chest x-ray
and laboratory tests as well. Once your medical has been completed the doctor will forward the medical
results to CIC.
Any costs related to the medical examination are your responsibility and are payable at the time of the
examination. Should your application be refused following the completion of your medical examination
these costs will not be refunded.
Please bring the following to your appointment:
- The attached Medical Report form (IMM1017E)
- Proper identification (proof of identity must include at least one government-issued document
with photograph and signature, such as a passport or national identity card)
- Eye glasses or contact lenses, if worn
- Any medical reports or test results that you may have as a result of previous or existing
medical conditions
- Four recent photographs (photos are not required if the panel physician is listed as eMedical
enabled on the CIC website listed above)
Note: It is important that you inform the panel physician of any previous or existing medical conditions.
Failure to do so will delay the processing of your medical examination.

IMM 1017 E (07-2015) GCMS

Citizenship and
Immigration Canada

PROTECTED WHEN COMPLETED - B

Citoyennet et
Immigration Canada

MEDICAL REPORT

Required for all clients.

Must be taken within six
months of the medical
examination.

CLIENT BIODATA AND SUMMARY

CLIENT INFORMATION
Family name

Given name(s)

PORTO

ROHAN CHRISTIAN

Date of Birth

Country of Birth

YYYY - MM - DD

2005/08/19

Gender

Philippines

Address

256 OAKVIEW DRIVE C/O NEW GRID IMMIGRATION CONSULT

ING
REGINA SK S4R 5K5
Canada
E-mail Address

Telephone no.

IMMIGRATION DETAILS
IMM Type:

Non EDE

UCI:

93824473

Application no.:

EP00185830

IME no: 12948561

*12948561*

IMMIGRATION MEDICAL EXAMINATION GRADING

A. No significant abnormal history or
abnormal findings present.

B. Significant abnormal history and/or significant abnormal

findings present.

Comments:

PANEL PHYSICIAN DECLARATION

Valid identity document (passport/national ID) sighted?

Do you have identity concerns?

No

Yes

If YES, please provide details:

No

Yes

I confirm that this immigration medical examination and report is a true and accurate record of my findings.
Panel Physician name

Panel Physician signature

Panel Physician no.

Date of IME submission

IMM 1017 E (07-2015) GCMS

YYYY

MM

DD