RMC PHARMACY TRAVEL CLINIC FORM

TRAVELER HISTORY FORM

Please complete and submit this form no less than 2 days prior to your Travel Health Appointment. RMC Pharmacy Travel Health Appointments cost $65 out of pocket. This cost covers our RMC Travel Health Certified Clinical Pharmacist reviewing your completed forms and preparing the appropriate medications/vaccines required. We will call you once your forms are reviewed to schedule an appointment. Thank you.
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
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:
Which date and time would you like to schedule your appointment? In the instance we cannot fulfill your requested time frame, we will contact you with other available options. Please book AT LEAST 2 days in advance. We will call you to confirm your scheduled appointment.*
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