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.

    All travel vaccine appointments include:

    🗺️ Itinerary Review – Advice based on where you’re going
    🌡️ Health & Safety Info – Country-specific risks and tips
    💉 Vaccines – Including Yellow Fever and others you may need
    🦟 Malaria Prevention – We only recommend anti-Malarias and insect protection. Seek prescriptions with PCP if medications are recommended.

    🤢 Travel Illness Tips – How to avoid common issues
    📄 Handouts – Easy-to-follow country info & travel advice

    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.

  • Travel Consult and Vaccination(s) Fee

  • Base fee for travel consultation is $80. Each person added to the appointments is an additional $25. Each additional country to the itenerary is an addiitonal $10. 

    Rarely do insurances cover specialty travel vaccines (e.g., Typhoid, Yellow Fever), or often the charge for these vaccines will be applied to deductibles or co-pays.  Due to this, any specialty travel vaccines will be expected to be paid in full at the time of service.  We will still attempt to bill in-network insurances and provide a refund if some of the costs are covered.

     

  • I have read and agree to pay the cost of the travel consult & vaccinations.*

  • Contact and Demographic Information for Person Traveling

  • Today
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  • Birthday*
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  • Race (Check all that apply)*
  • Ethnicity*
  • Gender Identity*
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  • Opt into text and voice reminders for future appointments*
  • Format: (000) 000-0000.
  • Departure date of the upcoming travel?*
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  • Insurance Information & Travelers for Travel Consultation

  • Which traveler(s) are coming to this travel consult and vaccine appointment?*

  • You have selected a travel consultation and vaccination appointment for yourself and your child(ren). Please list each child’s full name, date of birth, and whether they have the same insurance as you.

    **If a child’s insurance is different, please bring their insurance card to the appointment or upload their insurance card to this form**

  • You have selected a travel consultation and vaccination appointment for yourself and another adult(s). Please list the adult traveler(s) who will attend the appointment with you so we can schedule you together.

    **Each additional adult must complete their own travel form.**

    You may share this link: https://form.jotform.com/LC_PH/pre-travel-health-consult-form
    or visit: https://www.lccountymt.gov/Government/Public-Health/Immunizations/Travel-Immunizations or complete the form again at the end by clicking “Pre_Travel Form Fill Again.”

  • Do you have health insurance?*

  • Insurance: 

  • What is your health insurance plan (Check all that apply)?*

  • Policy Holder Information: 

  • Policy Holder's Date of Birth*
     - -
  • Relationship to Patient*
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  • Does your health insurance cover vaccines?*
  • Policy Holder Medicare Entitled to (Check all that apply)

  • Travel consult provided by Lewis and Clark Public Health nurse (review of immunization records, vaccines, pre-travel advice, medicines) is separate from the vaccine cost and is generally not covered by health insurance companies. LCPH nurses will advise you, if antibiotics are recommended (malaria, traveler's diarrhea) but they are unable to prescribe it. You will need to contact your healthcare provider to obtain the prescription.

    Estimated Cost as of Septemeber, 2023:

    -*******************************-

    Nurse Consult starts at: 

    1-2 people (up to 2 destinations) is $160

    *$20 per additional travler (after 2) and $40 for each additional destination  (after 2)

    Vaccine cost is seperate and additional to Nurse Consult cost listed above. Check with your insurance for vaccine coverage eligibility.  

    *Fee might be different if consult occurs offsite. Contact 406-457-8900

  • Did you access this form through Lewis & Clark Public Health's Website?
  • One options - Which traveler(s) are coming to this travel consult and vaccine appointment?
  • Will you be coming to this appointment with your children who will be traveling with you? (Vivi get full name and DOB and insurance question - do they have same insurance as you? - Yes/No) - If say no - be prepared to bring insurance card or upload it to this form).
  • Will another adult traveler be coming to this appointment with you?

  • Travel Plans

    Please complete the following questions about your travel history and future international trip.
  • Have you traveled internationally in the past?*
  • Rows
  • Rows
  • While traveling, where will you be staying? (Please check all that apply)*
  • What activities are you considering or have planned for your trip?*

  • Medical History

     

    Please complete the following questions about your medical conditions and current medication use. 

     

  • Are you pregnant?
  • Are you allergic to any of these food items listed below? (Check all that apply)
  • Are you allergic to latex?
  • Which of these health conditions do you have? (Check all that apply)
  • Have you every had Guillain-Barre' Syndrome?*
  • Do any of these affect your immune system?
  • Have you recently received blood transfusion?
  • Do you receive long-term aspirin therapy?*
  • Please select the boxes for health problems for which you take medications on regular basis:
  • Are you allergic to any medications?
  • Will you be taking antibiotics 72 hours prior to travel consult appointment?

  • Immunization History

     

    Please complete the following questions and attach copies of all your immunization records (and if applicable, your childs who is travelling with you). 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 visit MT DPHHS or call 406-444-5580.

  • Are you 60 years or older?*
  • Have you received any vaccinations in the past 4 weeks?
  • Have you had a serious reaction to a vaccination?
  • Will your child(ren) be travelling with you?

  • Montana imTrax Vaccination Consent Form for Children

    Child's:    Child's   Pick a Date   . 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      

  • Is there an additional child to provide a Montana imTrax Vaccination Consent Form?

  • Montana imTrax Vaccination Consent Form for Children

    Child's:    Child's   Pick a Date   . 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      

  • Is there an additional child to provide a Montana imTrax Vaccination Consent Form?

  • Montana imTrax Vaccination Consent Form for Children

    Child's:    Child's   Pick a Date   . 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      

  • Is there an additional child to provide a Montana imTrax Vaccination Consent Form?

  • Montana imTrax Vaccination Consent Form for Children

    Child's:    Child's   Pick a Date   . 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      

  • Is there an additional child to provide a Montana imTrax Vaccination Consent Form?

  • Montana imTrax Vaccination Consent Form for Children

    Child's:    Child's   Pick a Date   . 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      

  • Is there an additional child to provide a Montana imTrax Vaccination Consent Form?

  • Montana imTrax Vaccination Consent Form for Children

    Child's:    Child's   Pick a Date   . 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      

  • Is there an additional child to provide a Montana imTrax Vaccination Consent Form?

  • Montana imTrax Vaccination Consent Form for Children

    Child's:    Child's   Pick a Date   . 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      

  • Montana imTrax Vaccination Consent Form for Adults

    Adult:    Adult's   Pick a Date   . 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      

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  • You have selected that you do not understand the pay of cost for the travel consult and vaccinations and would like further information. Please let us know your name and best number to reach you and a Lewis and Clark Public Health Staff will contact you within 24-48 hours. Thank you. 

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