Citizenship and Citoyennet et PROTECTED WHEN COMPLETED - B

Immigration Canada Immigration Canada

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 Citoyennet et PROTECTED WHEN COMPLETED - B
Immigration Canada Immigration Canada

MEDICAL REPORT Required for all clients.

CLIENT BIODATA AND SUMMARY Must be taken within six
months of the medical
examination.

CLIENT INFORMATION
Family name Given name(s)

Butcon Ralph Gio

Date of Birth YYYY - MM - DD Country of Birth Gender

2001/01/05 Philippines M
Address

719 BRIAR CRESCENT

MILTON ON L9T 3Z7
Canada

E-mail Address Telephone no.

beth_lyleralph@yahoo.com
IMMIGRATION DETAILS

IMM Type: Non EDE IME no: 13469639

UCI: 9237-9412
Application no.: E000211621
*13469639*
IMMIGRATION MEDICAL EXAMINATION GRADING

A. No significant abnormal history or B. Significant abnormal history and/or significant abnormal

abnormal findings present. 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 YYYY MM DD

IMM 1017 E (07-2015) GCMS