Yellow Fever Vaccine Registration Logo
  • Yellow Fever Vaccination Registration Form

    Please complete the entire form to schedule your Yellow Fever vaccination appointment. Boone Drug takes your personal information seriously. This form is 100% HIPAA compliant.
  • Due to the HIPAA protections used on this form, you will no longer be able to make any changes to the information below once the form is submitted.

    If you need to reschedule or cancel your appointment, please email vaccines@boonedrug.com with your request.

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  • WARNING: Please be aware that individuals 60 years of age and over are at an increased risk of the more severe side effects associated with the yellow fever vaccine. These serious adverse events (vaccine associated neurologic disease (YEL-AND) and vaccine associated viscerotropic disease (YEL-AVD)) occur at a rate of 0.8 cases (YEL-AND) and 0.3 cases (YEL-AVD) for every 100,000 doses of YF vaccine distributed but these rate increases when looking at individuals 60 and over to 2.2 cases for every 100,000 doses distributed for YEL-AND and 1.2 cases for every 100,000 doses distributed for YEL-AVD.

    Please discuss with your primary care provider the risks vs the benefits of receiving the yellow fever vaccine as it pertains to your personal health and medical history.

  • Health Information

    Please complete all questions below.
  • PLEASE NOTE: If you have received a previous dose of the yellow fever vaccine, current recommendations are that a single dose of the yellow fever vaccine is sufficient for lifetime protection with very rare instances in which a booster dose is recommended. It is our facility's understanding that existing ICVP (yellow cards) with the 10-year validity listed will be accepted and valid as long as the certificate itself meets validity requirements under International Health Regulations (for example the card is still legible and your legal name has not changed) and should not need to be re-issued.

    If you have misplaced your ICVP (yellow card), it can ONLY be reissued by the clinic you received your initial yellow fever vaccine from.

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  • Travel Itinerary

    Please complete the following questions, if any changes are made to your itinerary after completing this form and before you attend your appointment, please bring those changes with you to your appointment.
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  • Your yellow fever vaccine will be valid on {theYellow211} . Please plan to arrive at your destination ON OR AFTER the date that your vaccine is VALID.

    Countries that REQUIRE proof of a VALID yellow fever vaccination for ALL individuals entering the country are:

    • Angola
    • Benin
    • Burkina Faso
    • Burundi
    • Cameroon
    • Central African Republic
    • Congo, Republic of the
    • Cote D'Ivoire (Ivory Coast)
    • Democratic Republic of the Congo (DRC)
    • French Guiana
    • Gabon
    • Ghana
    • Guinea-Bissau
    • Mali
    • Niger
    • Sierra Leone
    • South Sudan
    • Togo
    • Uganda

    Countries which the CDC RECOMMENDS yellow fever vaccination for ALL travelers 9 months of age or older include:

    • Angola
    • Argentina (with exceptions)
    • Benin
    • Bolivia (with exceptions)
    • Brazil (with exceptions)
    • Burkina Faso
    • Burundi
    • Cameroon
    • Central African Republic
    • Chad (with exceptions)
    • Colombia (with exceptions)
    • Congo (Republic of the)
    • Cote d’Ivoire (Ivory Coast)
    • Democratic Republic of the Congo (DRC)
    • Ecuador (with exceptions)
    • Equatorial Guinea
    • Ethiopia (with exceptions)
    • French Guiana
    • Gabon
    • Gambia
    • Ghana
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Kenya (with exceptions)
    • Liberia
    • Mali
    • Mauritania
    • Niger
    • Nigeria
    • Panama (with exceptions)
    • Paraquay
    • Peru (with exceptions)
    • Senegal
    • Sierra Leone
    • South Sudan
    • Sudan (with exceptions)
    • Suriname
    • Togo
    • Trinidad and Tobago (with exceptions)
    • Uganda
    • Venezuela (with exceptions)

    Countries which the CDC GENERALLY DOES NOT RECOMMEND yellow fever vaccination (where vaccination may be considered for a small subset of travelers at increased risk for exposure due to prolonged travel, heavy mosquito exposure, or inability to avoid mosquito bites) include:

    • Eritrea (with exceptions)
    • Rwanda
    • Sao Tome and Principe
    • Somalia (with exceptions)
    • Tanzania
    • Zambia (with exceptions)

    Other countries may require proof of yellow fever vaccination for any travelers arriving from countries with risk of YF virus transmission including those who have airport transits or layovers of over 12 hours in countries with risk of YF virus transmission. For further details regarding the countries with yellow fever recommendation or general recommendation exceptions and specific country entry requirements, please visit the CDC Website: Yellow Fever Vaccine & Malaria Prevention Information, by Country or contact the embassy of the country you will be travelling to. 

  • Informed Consent

    I certify that I am: (i) the patient and at least 18 years of age, or (ii) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of Boone Drug, Inc. to administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccination(s) and recognize the risks and benefits associated with the vaccine(s). I acknowledge that I have received, read, and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have chosen to receive. I authorize this vaccination information to be reported to my primary care provider (if available) and the State immunization registry.
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