Vaccine Questionnaire and Consent for Immunization

Travel consult Appointment

Let Hoagland Pharmacy provide your vaccination consultation for your future travel! Travel consultations are by appointment only for a $60 consultation fee per person. Our staff will let you know what vaccines are required or recommended for your destination as well as check the state vaccine registry to see what vaccines you are due for.
Patient Information

Appointment Required.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Patient Gender*

MaleFemale
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name (if applicable)

First NameLast Name
Email*
example@example.com
Last 4 of SSN
Used to look up insurance prior to appointment
Copy of Insurance Card, Front and Back

Travel consultation not billable, insurance used for any vaccines received
Cancelof
Where are you traveling? Give as much detail as possible.*
Please list all countries visiting so research can be done prior to your arrival.
When are you leaving? *
When are you returning? *
Please list any allergies:
Appointment*

Patient Names for Group (please complete all fields for each additional patient)

	Indicate Patient Needing Vaccine/Consult (Yes/No):	Patient Name:	Date of Birth (mm/dd/yyyy):	Patient Gender:	Patient Address:	Patient Cell Phone #:	Patient Email:
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6

By signing below I agree to pay all applicable charges for the travel consultation and any vaccines that I(we) choose to receive. I understand that if I cancel less than 24 hours prior to the appointment time I will receive a refund less $20 as a cancellation fee.
Signature*

Clear

My Products*

Travel ConsultationPlease change quantity to reflect the number of people that will be at the appointment.

$60.00 Quantity

Total

$0.00

Travel consult Appointment