PMPP TRAVEL CLINIC FORM Logo
  • TRAVELER HISTORY FORM

    Complete this form and bring it to the pharmacy clinic appointment along with vaccination records.
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  • Vaccination History

  • Have you received the following immunizations?

  • HIPAA PRIVACY CONSENT

  • By initialing below, the patient or the guardian of the patient understands that:

    • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
    • The Practice has a "Notice of Privacy Practices" document and the patient/guardian has the opportunity to review this notice
    • The Practice reserves the right to change the Notice of Privacy Practices at any time. 
    • The patient may revoke this consent in writing at any time and all future disclosures will then cease. 
    • The practice may condition treatment upon the execution of this consent. 
  • Initials * Date*

  • FINANCIAL POLICY

  • By initialing below, I attest that I understand and agree to the following regarding fees for services provided by the Travel Clinic:

    • Total claim/fees for services provided by the Travel Clinic are to be paid in full at time of services rendered
    • The Travel Clinic will submit claims/fees for services provided to health insurance carriers.
    • If Vaccinations/Medications are not covered by your Insurance, you will responsible for all costs.
  • Initials * Date*

  • INSURANCE INFORMATION

  • REFUSAL OF RECOMMENDED IMMUNIZATIONS

  • By initialing below, I attest that I understand the risks and benefits of the immunizations that were recommended to me by the Travel Clinic. I understand that vaccination/immunizations from illness or disease is voluntary. For any reason, if I choose not to accept the recommended immunizations, I do not hold the Travel Clinic or any of its personnel accountable for any risks incurred for being unvaccinated and unprotected from potential illness or disease. 

  • Initials * Date*

  • CONSENT TO TREAT

  • I understand the interactions, allergies, warnings, precautions and potential adverse reactions regarding the medications and immunizations that I reeived at the Travel Clinic. I have read the information on the vaccine information statement sheet (VIS from the CDC) and understand the information. I voluntarily consent to receive the mediations and/or immunizations. 

    By signing below, I hereby consent to evaluation, testing and treatment for me or the named patient as directed by the physician or his or her designee at the Travel Clinic. By signing below, I certify I have read and understand and agree to the consent on this page including the HIPAA PRIVACY CONSENT, FINANCIAL POLICY, REFUSAL OF RECOMMENDED IMMUNIZATIONS, AND CONSENT TO TREAT. 

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