RMC PHARMACY TRAVEL CLINIC FORM

TRAVELER HISTORY FORM

Please complete and submit this form about 2 to 3 days prior to your Travel Health Appointment with RMC Pharmacy.
Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
How did you hear about us?

PhysicianSchoolHealth DepartmentInternetCDC or ISTMSocial MediaFriend/FamilyChurchInsurance
Primary Care Physician*

NameLast Name
Physician Phone Number*
Please enter a valid phone number.
Valid ID Number (Passport #)*
Please tell us which countries you will be visiting:*
Travel Dates*
Purpose of Trip (check all that apply)*

VacationEducation/ResearchVisit friends or familyMissionary/volunteer/humanitarian reliefWork (urban, office based or conference)Work (rural, outdoors, or in local community)Other
Planned Activities (please list all):*
Will you be visiting areas that are rural?*

YesNoMaybe
Will you be visiting areas that are urban?*

YesNoMaybe
Will you be ascending to high altitudes? (2500 metres [8200 ft] or higher)*

YesNoMaybe
Will you be working with potential exposure to body fluids? (e.g. medical/dental work)*

YesNoNot sure
Accomodations (check all that apply)*

Resort/large hotelSmall hotel, guest house, B&BCruise ShipPrivate home (with locals)Private home (with relatives)Primitive CampingUp-scale camp/lodgeDormitory/hostelOther
Previous International Travels: Please list in the following format: "Country visited - Arrival date - Departure Date" e.g. India - 01/01/2022 - 03/01/2022*
Please list any food or medication allergies:*
Please list any current medical conditions:*
Are you currently immunocompromised?*

YesNoNot Sure
Vaccination History
Have you received the following immunizations?
Cholera*

NoMaybeYes (please type date of vaccination below)
Hepatitis A*

NoMaybeYes (please type date of vaccination below)
Hepatitis B*

NoMaybeYes (please type date of vaccination below)
HPV*

NoMaybeYes (please type date of vaccination below)
Influenza*

NoMaybeYes (please type date of vaccination below)
Japanese Encephalitis*

NoMaybeYes (please type date of vaccination below)
Meningococcal Meningitis*

NoMaybeYes (please type date of vaccination below)
Measles/Mumps/Rubella*

NoMaybeYes (please type date of vaccination below)
Pneumococcal*

NoMaybeYes (please type date of vaccination below)
Polio*

NoMaybeYes (please type date of vaccination below)
Tetanus*

NoMaybeYes (please type date of vaccination below)
Typhoid*

NoMaybeYes (please type date of vaccination below)
Varicella*

NoMaybeYes (please type date of vaccination below)
Yellow Fever*

NoMaybeYes (please type date of vaccination below)
Zoster (shingles)*

NoMaybeYes (please type date of vaccination below)
Other Vaccines (please type the name and date received of any other vaccines to the best of your knowledge):*
Have you ever had an adverse reaction to an immunization?*

NoYes (please explain in box below)
Are you currently using corticosteroids, receiving cancer treatment, or other immunosuppressive therapy?*

YesNo
Please list all over-the-counter, herbal, hemeopathic products, vitamins, supplements, etc: e.g. Daily multivitamin, Advil for back pain, and Zyrtec for allergies*
For women: Are you pregnant now, or do you suspect that you might be pregnant?*

YesNo
For women: Do you plan to become pregnant in the next 6 months?*

YesNo
Please list any questions or concerns you may have:
Emergency Contact Name*
Emergency Contact Relation*
Emergency Contact Address*
Emergency Contact Phone*
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 blanks* Dateblank*
FINANCIAL POLICY
Name of Insurance
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 be responsible for all costs.
RMC Pharmacy Travel Health Appointments cost $65. This cost covers our RMC Clinical Pharmacist reviewing your completed forms and preparing the appropriate medications/vaccines for your scheduled appointment.

I understand that I will still be charged and responsible for the $65 appointment fee if I do not show up to my scheduled appointment.
Initials blanks* Dateblank*
INSURANCE INFORMATION
Cardholder Name
Member ID Number (or subscriber ID number)
Insurance Group Number
Rx BIN Number
Rx PCN Number
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 blanks* Dateblank*
CONSENT TO TREAT
I understand the interactions, allergies, warnings, precautions and potential adverse reactions regarding the medications and immunizations that I received 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, understand and agree to the consent on this page including the HIPAA PRIVACY CONSENT, FINANCIAL POLICY, REFUSAL OF RECOMMENDED IMMUNIZATIONS, AND CONSENT TO TREAT.
Signature*

Clear
Today's Date*

MonthDayYear
Date
This form/consent was signed by (full name):
Relationship to the person who signed for the patient:
Should be Empty:

TRAVELER HISTORY FORM

Vaccination History

Have you received the following immunizations?

HIPAA PRIVACY CONSENT

FINANCIAL POLICY

INSURANCE INFORMATION

REFUSAL OF RECOMMENDED IMMUNIZATIONS

CONSENT TO TREAT