Immigration Canada (IRCC) eMedical Information Form

Immigration Canada (IRCC) eMedical Information Form

Please provide the applicant’s details and upload the required documents. Your information will be sent to the clinic after you submit.
Applicant Personal Details

Enter the applicant’s information exactly as shown on the passport.
First name(s)*
Middle name(s)
Surname (family name)*
Date of birth*

DayMonthYear
Date
Age (in years)*
FemaleMaleAnother gender identityPrefer not to say
Country of birth*
YesNo
Parent / legal guardian full name (If under 18)

First NameLast Name
Relationship to applicant
Medical Report Form (IMM 1017E)

Provide your case details and upload the medical form if you have it.
YesNo
Immigration case number
Upload Medical Report Form (IMM 1017E) (if available)

Cancelof
Upfront medical type*
Family - EDE (Excessive Demand Exempt)StudentVisitorWorker
Contact Information

Provide the best contact details for appointment coordination and follow-up.
Email*
example@example.com
New Zealand contact number*

Area CodePhone Number
Physical street address (New Zealand only)*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Passport & Visa Documents

Upload clear images/photos. Ensure all details are readable.
Upload a picture of the passport*

Cancelof
Passport number*
Name of Country on Passport cover*
Upload a passport-style photo*

Cancelof
YesNo
Upload current New Zealand visa document

Cancelof
Submission Confirmation

Please review your information before submitting.
By submitting this form, you confirm the information provided is accurate and will be emailed to the clinic.
Should be Empty:

Immigration Canada (IRCC) eMedical Information Form

Applicant Personal Details

Medical Report Form (IMM 1017E)

Contact Information

Passport & Visa Documents

Submission Confirmation