Pre-Travel Health Consultation Form

Pre-Travel Health Consultation Form
You are encouraged to book your travel clinic appointment at least 4-6 weeks before your trip. It may take 3 weeks to get the first available appointment and it may take few months to have protection from the vaccines. It is important to book early since many vaccines come in a series and need to be administered according to a specific schedule.

This form must be completed and returned before you can schedule a travel consultation appointment. The information about your entire travel itinerary will help the nurse determine which vaccinations are needed, and precautions you may need to take to keep you safe and healthy during your trip. We need as much information as you have including; layovers, destinations, accommodations, activities, medications, and health conditions.

Please upload any immunization record(s) you currently have before you submit this form. If you are planning on obtaining a Yellow Fever vaccine and you are aged 60 years or older, you will need a referral/prescription from your medical provider. The medical/prescription can be uploaded with your immunizations record(s), or you can have your medical provider send it directly to us via secure fax at 406-457-8997.

Policy Holder ID/Number
Policy Holder Medicare Number
Last 4 digits of Policy Holder Social Security Number
Policy Holder Medicare Entitled to (Check all that apply)

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Immunization History

Please complete the following questions and attach copies of all your immunization records. Please ask your family, high school, childhood physician, primary care provider, and/or your home state’s immunization registry for copies of your immunization records. For Montana contact: MT DPHHS 406-444-5580

Yellow fever vaccine maybe required or recommended based upon your travel itinerary. For individuals aged 60 years or older a referall or prescription from medical provider is required prior to administering the vaccine. Please attach it at the end of this form.
Have you received any vaccinations in the past 4 weeks?*

YesNoNever had vaccination
Have you had a serious reaction to a vaccination?*

YesNo
If yes, please describe your reaction to a vaccination. *
Montana imTrax Vaccination Consent Form for Children

Child's: First and Last Name Child's Date of Birth . I authorize my health care provider and a public health agency to collect and enter my child’s immunization records into the Department of Public Health and Human Services’ Immunization Information System (IIS). The IIS is a confidential, computer system that contains immunization records. I understand that information in the registry may be released to a public health agency as well as my health care providers to assist in my child’s medical care and treatment. In addition, information may be released to child care facilities and schools in which my child is enrolled to comply with state immunization requirements. I understand that I can revoke this authorization and have my record removed at any time by contacting my local health department. Please Initial
Montana imTrax Vaccination Consent Form for Adults

Adult: First and Last Name Adult's Date of Birth . I authorize my health care provider and a public health agency to collect and enter my immunization records into the Department of Public Health and Human Services’ Immunization Information System (IIS). The IIS is a confidential, computer system that contains immunization records. I understand that information in the registry may be released to a public health agency as well as my health care providers to assist in my medical care and treatment. In addition, information may be released to schools in in order to comply with immunization requirements. I understand that I can revoke this authorization and have my record removed at any time by contacting my local health department. Please Initial
Upload copies of all your immunization records. If you are 60 years or older and are planning on obtaining yellow fever vaccine, please attach referral/prescription from your medical provider.

(acceptable file format: pdf, doc, docx, zip, jpg, jpeg, png, gif)
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