Visa Application Questionnaire Step 2.2 | CADUCEUS INTERNATIONALPreliminary Application and Questionnaire for Visa travel to the US
1 Accept: Terms of Service
2 Preliminary Visa Application
3 Personal Information
4 Personal Information: part 2
5 Address and Phone Information
6 Passport Information
7 Travel Information
8 Travel Companions Information
9 Previous U.S. Travel Information
10 U.S. Point of Contact Information
11 Family Information: Relatives
12 Family Information: Spouse
13 Present Work/Education/Training Information
14 Previous Work/Education/Training Information
15 Additional Work/Education/Training Information
16 Security and Background: Part 1
17 Security and Background: Part 2
18 Security and Background: Part 3
19 Security and Background: Part 4
20 Security and Background: Part 5
21 Submit for review: Questionnaire
- By Using Our Website and Services, you agree to the following terms Welcome to Caduceus International’s website and online services (“Caduceus International Site” or the “Site”), an online information and communications service provided by Caduceus International, a registered company in South Carolina, (“Caduceus International” or “CI” or “Us”). This policy is intended to cover the uses for all of the Site, although additional conditions, restrictions and privacy policies may apply.
- Enter the complete name of the primary applicant. (the person seeking treatment, if a Patient. Or, the person applying for a US Visa.) Note* A valid Visa is required for entry into the United States. If applying for a US Visa, each traveler will need to file an application.
- In order to send confirmation emails that contain registration, appointment, and other important details regarding your case, we need a valid email address for the person (you) filing out the application.
- select an option below that best describes why you are submitting the questionnaire
- medical care includes surgeries, cancer treatments, diagnosis by a doctor, and any types of appointments where an individuals health is the reason for attendance.
- Your answers indicate you currently hold a valid US travel Visa and that you Do Not seek care or treatment at this time. So that we can better understand how to assist you, please call us at +1.864.502.8472 to speak with one of our Client Consultants, or send us an email [email protected] and include the subject: Valid Visa Form Support
- Your answers indicate you are unsure if you hold a valid US travel Visa. So that we can better understand how to assist you, please call us at +1.864.502.8472 to speak with one of our Client Consultants, or send us an email [email protected] and include the subject: Valid Visa Unsure Support
- Your answers indicate you are unsure if you seek care or treatment in the United States. So that we can better understand how to assist you, please call us at +1.864.502.8472 to speak with one of our Client Consultants, or send us an email [email protected]tional.com and include the subject: USA Treatment Unsure Support
- Enter the complete name of the person applying for a US Visa and that seeks care in the USA. (If more than one individual is applying for a Visa, each person is required to submit an application)
- Enter the complete name of the person applying for a US Visa (If more than one individual is applying for a Visa, each person is required to submit an application)
- Has a doctor diagnosed the condition and provided medical records?
- Click the (+) sign to add additional travelers. Provide the name(s) of all other persons that will accompany the primary applicant (NOTE: each traveler will require an individual US Visa application be completed and submitted on their behalf)
Given names Maiden name (Middle) Surname
- Select all that apply
- Please briefly explain why treatment in the USA is preferred versus treatment in another country. This will aid your Caduceus Consultant in designing your customized client package.
- Help: Other Names Other names used include your maiden name, religious name, professional name, or any other names which you are known by or have been known by in the past.
- Click the (+) to list additional names used that are different from the name shown on your passport
Given names Maiden name (middle) Surname
- Telecodes are 4 digit code numbers that represent characters in some non-Roman alphabet names.
- Based on your answer of "Other" for applicants "Marital Status", please explain.
- Date of Birth must match date shown on the passport.
- Select your Country/Region of Origin (Nationality)
- Help: A national identification number, national identity number, or national insurance number is used by the governments of many countries as a means of tracking their citizens, permanent residents, and temporary residents for the purposes of work, taxation, government benefits, health care, and other governmentally-related functions. The number appears on identity documents issued by several of the countries.
- Help: You must provide a primary phone number. The primary phone number should be the phone number at which you are most likely to be reached; this could be a landline or cellular/mobile number. If you have an additional landline or a cellular/mobile number please list that as your secondary phone number.
- Help: Passport/Travel Document Number Enter the information on the travel document you will be using when traveling to the U.S. Your travel document should be a valid, unexpired passport or other valid, unexpired documentation that is sufficient to establish your identity and nationality.
- Help: Passport Book Number The Passport Book Number is commonly called the inventory control number. You may or may not have a Passport Book Number on your passport. The location of the Passport Book Number on your passport may vary depending on the country that issued your passport. Please contact your passport issuing authority if you are unable to determine whether or not your passport contains a Passport Book Number.
- (if shown on your passport or travel document)
- Help: Expiration Date In most cases, your Passport/Travel Document must have at least six months of validity beyond the date of your visa application and/or your arrival in the United States. dd/mm/yyyy
- Passport/Travel Document Number
- Explain what happened
- [Persons traveling for Medical Tourism, Visiting for personal reasons, or Visiting for Business, Select TEMP. BUSINESS PLEASURE VISITOR (B)]
- If you are unsure of your Date of Arrival in the US or Date of Departure from the US, please provide your anticipated estimate of when you think you may travel.
- If known, please provide the arriving Flight number and/or Airline
- City / Airport code flight arrives in the US
- If unknown please estimate your trip to be 4 weeks from your anticipated arrival
- (Select the State that issued the license from the drop-down)
- Help: Contact Your U.S. Point of Contact can be any individual in the U.S. who knows you and can verify, if necessary, your identity. If you do not personally know anyone in the U.S., you may enter the name of the store, company, or organization you plan to visit during your trip.
- Your U.S. Point of Contact can be any individual in the U.S. who knows you and can verify, if necessary, your identity. If you do not personally know anyone in the U.S., you may enter the name of the store, company, or organization you plan to visit during your trip.
- Father's Date of Birth
- Is your father in the US?
- Father's US Immigrant Status
- Mother's Date of Birth
- Is your mother in the U.S.?
- Mother's Immigration Status
- If any Names are Not Known, Type "Unknown" for the Name(s)
- Spouse's Date of Birth
- Help: Describe what your daily job duties / functions are. Examples: Do you Manage employees? If yes, how many employees do you manage and what tasks do they do that you oversee? Do you run the operations? If yes, how large of a company is it and what types of products or services do you provide?
Previous Work/Education/Training InformationNOTE: Provide your employment information for the last five years that you were employed, if applicable.
- Select these Boxes if you Do Not Know the Surname or the Given Names of Your Supervisor at Previous Employer
- Help: Level of Education: You must answer "YES" to this question if you have ever attended, for any length of time, a high school/secondary school (or its equivalent in your country) or college, university, graduate school, a doctoral program, or a vocational program.
- Help: Course of Study For middle school/junior high or high school course of study please indicate “Academic” or “Vocational.” For all other educational levels please indicate your major or concentration.
Additional Work/Education/Training InformationNOTE: Provide the following work, education, or training related information. Provide complete and accurate information to all questions that require an explanation.