USA: CLIENT’S DECLARATION

A document to print and sign before consulting Dr. AUBERT

Hello,

I am Dr. AUBERT. You will soon be meeting with me (or one of my substitutes) for your medical examination (EMI) for immigration to the US. Here is a document that I would like you to print, read, and complete before your consultation. Please bring it with you on paper. By signing this document, you authorize me to share information about your health with the US authorities. If there are several of you, a separate document must be completed for each of you (adults and children, but adults have to sign for children under 15). If you do not have a printer, or if you do not have time, don’t worry, I will give you the same document to sign in the waiting room.