SUNIL LALLA, MD FCCP
Please provide a copy of Driver's License or Passport Number to accompany I-693
If you do not speak English, please provide the following information about the interpreter:
Interpreter's Information
IMMIGATION PHYSICALS ARE NOT COVERED BY HEALTH CARE INSURANCES.
**PAYMENT IS DUE AT THE TIME OF SERVICES. THANK YOU**
MEDICAL HISTORY
Specify date diagnosed (mm-yyyy) :
Specify date treatment completed (mm-yyyy) :
Specify date diagnosed (mm-yyyy) :
Specify date treatment completed (mm-yyyy) :
specify date diagnosed (mm-yyyy) and treatment: completed (mm-yyyy)
Please enter date diagnosed (mm-yyyy
(Please specify}
(including loss of arms or legs specify)
(List all current medications)
(List all previous surgeries)
Obstetrics
Estimated delivery date (mm-dd-yyyy)
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