Welcome. Please complete this travel/medical profile questionnaire for each person that will be included in your travel medicine appointment.
Note that this questionnaire cannot be saved, and all inputs will be erased if you leave the questionnaire before clicking "Submit Your Information." Before starting, it is recommended to have the following items handy:
Primary care physician name and address
Your travel itinerary (including departure and return date along with cities + country you will land in OR travel through)
Pharmacy name/location
Dates of vaccines or previous disease
All current medications (prescribed and non-prescribed)
Allergies and active medical conditions
Once the questionnaire is submitted, we will contact you to schedule the appointment.
We DO NOT bill any insurance. Payment for your visit, including consultation and immunizations, are your responsibility. Payment is expected at the time of service. We accept Visa, MasterCard, American Express, cash or check.
We look forward to serving you. If you have questions, please do not hesitate to call our office.