Medical fees .pdf
À propos / Télécharger Aperçu
Ce document au format PDF 1.4 a été généré par PDFMerge! (http://www.pdfmerge.com) / iText® 5.5.8 ©2000-2015 iText Group NV (ONLINE PDF SERVICES; licensed version), et a été envoyé sur fichier-pdf.fr le 05/10/2016 à 19:23, depuis l'adresse IP 124.122.x.x.
La présente page de téléchargement du fichier a été vue 574 fois.
Taille du document: 328 Ko (5 pages).
Confidentialité: fichier public
Aperçu du document
COUNTRY
CHAPTER
USA
The
UNITED STATES
OF AMERICA
BY THE GOVERNMENT OF
THE UNITED STATES OF AMERICA
KNIGHTSBRIDGE DOCTORS PRICING INFORMATION
Item
Description
Unit Price £
1
Basic Medical Examination – Adult (15 years of age and older)
250.00
2
Basic Medical Examination – Child (under 15 years of age)
120.00
3
Bacteriological examination of Sputum x3
115.00
4
DNA Collection Adult
100.00
DNA Collection Child
50.00
5
Non-Immigrant Visa
305.00
6
Drug & Alcohol Lab Test Fee (each)
50.00
7
Chain of Custody Drug Screen
80.00
Supplemental Charges for vaccination against:
8
Diphteria, tetanus and pertussis
45.00
9
Tetanus, diphtheria & polio
35.00
10
Measles, Mumps and Rubella
45.00
11
Hepatitis B
40.00
12
Hepatitis A and Hepatitis B Combined
40.00
13
Varicella
14
Pneumococcal - Adult
40.00
15
Pneumococcal - Child
75.00
16
Influenza
22.00
17
Meningococcal MCV
35.00
18
Rotavirus
67.00
19
Hepatitis A
40.00
20
Hepatitis B Child
40.00
21
DTaP + Hib
45.00
Syphillis Treatment (if available) or Private Prescription Cost for Treatment
Drug Screen
Immunity Screen for Measles
Immunity Screen for Mumps
Immunity Screen for Rubella
IV018a Medical Questionaire Updated May 2015. Page 6
Not available
50.00
65.00
65.00
65.00
Vaccination Requirements
Age
Vaccine
DTP/DTaP/DT
Birth - 1
2 - 11
month
months
12 months to 4 years
5 - 6 years
7-
18 -
17
64
years years
No
Yes
≥ 65
years
No
Yes, ≥ 7 years old
Td/Tdap
(for Td); 10-64
No
years old (for
Tdap)
Polio: IPV or
OPV
No
MMR
Yes
No
No
Yes if born in 1957 or later
No
Varicella
(Chickenpox)
No
Not available
Yes
in the UK
Pneumococcal
No
Yes, through 59 months of age
(for PCV)
Birth 11
months
Hepatitis A
No
12 - 23
24 months to ≥ 65
months
years
Yes
No
Age
Vaccine
Hepatitis B
≥ 18
Birth - 18 years
years
Yes, through 18 years of age
No
Age
Vaccine
Hib
Birth - 1
2 - 59
month
months
No
Yes
≥ 60 months
No
Age
Vaccine
Birth - 5
6- 59
60 months to
months
months
49 years
7
IV018a Medical Questionaire Updated May 2015. Page 7
No
(for
PPV)
Age
Vaccine
Yes
≥ 50 years
Yes
Influenza
No
Yes
No
Annually each flu
season
Age
Vaccine
Meningococcal
(MCV/MPSV)
Birth - 10
11 - 18
years
years
No
Yes
19 years to ≥ 65 years
No
Age
Vaccine
Birth 1
month
Rotavirus
No
12
2-6
months
months 5 - 6
to 4
years
years
7-
18 -
17
64
≥ 65 years
years years
Yes
No
DTP=diptheria and tetanus toxoids and pertussus vaccine;
DTAP=diphtheria and tetanus toxoids and acellular pertussis vaccine;
DT=pediatric formulation diphtheria and tetanus toxoids;
Td=adult formulation tetanus and diphtheria toxoids;
IPV=inactivated polio vaccine (killed);
OPV=oral polio vaccine (live);
MMR=combined measles, mumps, rubella vaccine;
Hib=Haemophilus influenzae type b conjugate vaccine;
PCV=pneumococcal conjugate vaccine;
PPV=pneumococcal polysaccharide vaccine.
8
IV018a Medical Questionaire Updated May 2015. Page 8
U.S. MEDICAL QUESTIONNAIRE
(MUST be completed and signed by applicant prior to medical appointment)
CASE NUMBER:
VISA CATEGORY:
NAME:
(First)
(Last)
DATE OF BIRTH:
BIRTHPLACE: (City/Country)
PRESENT COUNTRY OF RESIDENCE:
PRIOR COUNTRY:
NATIONALITY:
CURRENT ADDRESS:
TEL:
INTENDED U.S. ADDRESS:
(Middle)
AGE:
GENDER: male
OCCUPATION:
EMAIL ADDRESS:
HEIGHT (in centimetres):
WEIGHT (in kilos):
1
Have you ever been hospitalized (including psychiatric admission)?
2
Have you been investigated or treated for any major illnesses?
3
Have you ever had any kidney or liver disease?
4
Have you ever had any mental disorder or depression?
5
Have you ever used drugs?
6
Have you ever had an addiction to or abused alcohol?
7
Have you had any form of treatment or investigations for alcohol
or drug abuse?
Have you ever caused deliberate injury to yourself or others?
8
9
10
11
female
YES
NO
Have you ever been arrested, convicted or received a warning for
any drug or alcohol offense (including driving)?
Do you take any medication? (Please list all medications on a
separate sheet)
Are you pregnant?
If the answer is yes, please provide evidence of pregnancy/copy of pregnancy test result.
Date of last period:
DATE:+
Expected delivery date:
SIGNATURE:
IV018a Medical Questionaire Updated May 2015. Page 9




