Medical Examination Instructions

PROTECTED WHEN COMPLETED - B

Citizenship and
Immigration Canada
Citoyennet et
Immigration Canada
IMM 1017 E (12-2012) GCMS
Medical instructions are issued when an application has been processed to the stage where the required
medical examination(s) should be undertaken. Please read the following instructions carefully.
The medical examination must be performed by a physician from the CIC list of panel physicians. This
list is available by accessing the following website: http://www.cic.gc.ca/dmp-md/medical.aspx.
You should identify a panel physician in your area and 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.
Medical examination results are valid for a twelve month period from the date of the examination.
All costs related to the medical examination, if applicable, are your responsibility and are payable at the time
of the examination. Should your application be refused following the completion of your medical examination
the costs will not be refunded.
Please bring the following to your appointment:
- The attached medical report form
- Proper identification (proof of identity must include at least one document with photograph and signature
such as a passport, driver's licence 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, if the panel physician is not eMedical enabled (note: panel physicians
that are eMedical enabled are indicated 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


Saudi Ground Services-Terminal 1 King Khalid nter
national Airport
Riyadh Riyadh 11483 13000
Saudi Arabia
nabeela.45@gmail.com +966537283491