Medical Examination Instructions

PROTECTED WHEN COMPLETED - B

Citizenship and
Immigration Canada
Citoyennet et
Immigration Canada
IMM 1017 E (12-2012) GCMS
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 60 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/dmp-md/medical.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.
If YES, please provide details:
IME no:
Do you have identity concerns? Valid identity document (passport/national ID) sighted?
PROTECTED WHEN COMPLETED - B
Date of Birth
Country of Birth
Given name(s) Family name
Telephone no.
Citizenship and
Immigration Canada
Citoyennet et
Immigration Canada
IMM 1017 E (12-2012) GCMS
Gender
E-mail Address
PANEL PHYSICIAN DECLARATION
Comments:
Panel Physician no.
Date of IME submission
B. Significant abnormal history and/or significant abnormal
findings present.
A. No significant abnormal history or
abnormal findings present.
IMMIGRATION MEDICAL EXAMINATION GRADING
I confirm that this immigration medical examination and report is a true and accurate record of my findings.
Panel Physician name
MM DD YYYY
IMMIGRATION DETAILS
IMM Type:
UCI:
No Yes
No Yes
Panel Physician signature
CLIENT INFORMATION
Required for all clients.
Must be taken within six
months of the medical
examination.
MEDICAL REPORT
CLIENT BIODATA AND SUMMARY
Application no.:
YYYY - MM - DD
Address
de Paula Medeiros Marina
1991/11/12 Brazil F
203-120 Italina Pereira Motta
Vitoria jardim camburi 29090-370
Brazil
+552835361716
Non EDE
*11638810*
11638810
91772492
S300666761