International Travel Clinic Appointment Request- Midland County Department of Public Health

Use this form to request an appointment with the International Travel Clinic at the Midland County Department of Public Health (MCDPH).

Appointment requests will be reviewed during normal clinic hours (Monday-Friday 8am-5pm), and we will contact you to schedule an appointment based on your responses.

If you are experiencing a medical emergency, call 911 or proceed to the nearest emergency room.

This form is secure and HIPAA-compliant. Please provide as much detail as possible.

1. Contact Information: *This question is required.

First Name:
Last Name:
Date of Birth:
Phone Number:

2. What is your travel destination? (be as specific as possible, and if traveling to multiple locations, include all locations) *This question is required.

3. What is your date of departure? *This question is required.

4. How long will you be traveling? *This question is required.

5. What is your reason for travel? (check all that apply) *This question is required.

Pleasure
Business
Mission trip
Other - Write In Please enter an 'other' value for this selection.

6. Do you take any immunosuppressive medications or have an autoimmune disease or condition? *This question is required.

Please enter an 'other' value for this selection.

7. Will others be traveling with you and seeking services from the International Travel Clinic at the MCDPH? *This question is required.

8. Is there anything else you would like us to know?