Travel Clinic Pre-Appointment Form

Travel Consultation Pre-Appointment Form

Please register using the form below at least 48 hours prior to your appointment.
Each individual will need to fill out their own form while also stating the total number of individuals attending together. This helps us access and organize everyone's vaccine records ahead of time
If you have insurance that pays for prescriptions, bring along your card(s) so we can bill your insurance on your behalf. If you have vaccination records, please bring them to your appointment.

If you’re unable to register using the form below, please call the pharmacy at least 48 hours in advance and we can take your information down prior to the appointment.
Select Location*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Is the provided phone number a Home or Mobile number?

MobileHome
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
ALBERTA HEALTH CARE NUMBER*
Date of Birth*

MonthDayYear
Date
How many people will be attending this appointment? (NOTE: Each individual will need to fill out their own form while also stating the total number of individuals attending together. This helps us access and organize everyone's vaccine records ahead of time)*

Just myselfTwoThreeFourFive or more
If you are attending as a group, please state the name the appointment was made under
Date of Appointment

MonthDayYear
Date

Travel Consultation Pre-Appointment Form