Immigration Scheduling Form — Insight Primary Care

Before your appointment: Complete this form in full and submit it — we will reach out by email to confirm your appointment time. We typically book 1–3 weeks out, so please plan accordingly. Bring your passport to your exam.

✅

Thank you!

We've received your scheduling request and will contact you soon by email to confirm your appointment.

Your submission ID is —
Please save this number in case you need to reference your request.

Patient Information

Full Name (as it appears on passport)*

Date of Birth*

Gender*

Street Address*

City*

State / Province*

Zip / Postal Code*

Country*

Phone Number*

Email Address*

Passport Information

Passport Number*

Issuing Country*

Country of Birth*

Date of Issue*

Date of Expiration*

III

Immigration Information

Immigrating to*

Australia

Canada

New Zealand

Australia - Additional Details

Exam Type

HAP ID Number (if assigned)

Canada - Additional Details

Exam Type

IME Number (if assigned)

New Zealand - Additional Details

Exam Type

INZ Number (if assigned)

⚠️ Important: Please make sure to bring your passport with you to your physical examination appointment. We are unable to see you without it.

Medical History

Please answer all questions honestly. If you select Yes, an explanation field will appear. This information is kept confidential and used solely for your immigration medical exam.

We will contact you by email to confirm your appointment time.

Something went wrong. Please try again or call us at 303-377-2494.