Ble): Attach image Family name: Gender: Given name: Date of birth (YYYY-MM-DD): Identity document seen? No Yes Document type: Passport Government issued photo ID If you have any concerns that the individual presenting to you does not match the identification and photo of the individual above, please notify my office immediately. Referred to (Specialist name / address): Referred by (Panel Physician name / address): Reason for referral: Report to include: • Clinical findings with c.
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How to fill out the Canada IMM 5734 E online
The Canada IMM 5734 E form, also known as the specialist's referral form, is an essential document for referring individuals for specialized medical assessments. This guide provides clear, step-by-step instructions on how to accurately complete the form online.
Follow the steps to fill out the Canada IMM 5734 E form accurately
- Click ‘Get Form’ button to obtain the form and access it for editing.
- Fill in the date section using the YYYY-MM-DD format to indicate the date of completion.
- Enter the unique client identification (UCI) number in the designated field.
- Provide the immigration medical examination (IME) number if applicable.
- Include the unique medical identifier (UMI) number if available.
- Attach an image if required, following the specified guidelines.
- Input the family name of the individual being referred.
- Select the gender of the individual from the provided options.
- Enter the given name of the individual accurately.
- Fill in the date of birth using the YYYY-MM-DD format.
- Indicate whether the identity document was seen by selecting yes or no and specify the document type, such as passport or government issued photo ID.
- In the referral section, clearly provide the name and address of the specialist to whom the individual is being referred.
- Fill in the name and address of the panel physician who is making the referral.
- Specify the reason for the referral in a clear and concise manner.
- Ensure that the report to be included covers all listed clinical findings, diagnosis, pathology report, treatment recommendations, prognosis, and copies of diagnostic tests.
- Complete the specialist declaration by confirming the examination of the client and signing the document.
- Input the signature date in the YYYY-MM-DD format.
- Review the completed form, make any necessary corrections, and save the changes.
- Download, print, or share the completed form as needed to return it along with the medical report.
Complete the Canada IMM 5734 E form online to ensure accurate and efficient processing.
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