One of my friend has REF for same medical exam for her wife due to pregnancy, he replied REF with medical exam and immunation report and he is still wating for final approve.
there are three thoughts of train
1. it might tigger REF and send documentation prior to REF and save some time.
2 it might not tigger REF at all.
3 if you send document without REF then it will take long time to macthup information with your case becuase REF has tracking information, so if you send with REF, it will take little time compare to unsoliciated mail/ information mention in option 1.
it's about taking chance, everybody has different view.
Thanks,
JB