Travel Vaccine and Yellow Fever Consultation Form

Travel Consult and Yellow Fever Vaccine Appointments

Yellow Fever vaccines are required or strongly recommended for travel to certain countries. Let Gibbs Pharmacy provide your vaccination and required yellow fever travel consult! We also offer general travel consultations for those who aren't sure what vaccines they may need before a big trip!
Why is a pre-travel consultation required?
- The CDC requires a "Pre-Travel Consultation" for people receiving the Yellow Fever Vaccine. Our consultation fee is $50. This will be charged at the time of your appointment.
  - You will get a lot of helpful and important information regarding your travels and recommended vaccinations.
- The Yellow Fever Vaccine cost is $350
  - If you have insurance, we process prescription insurance to see if they will help cover some or all of the cost.
  - Uninsured or cash-pay patients are welcome
- For families that just need one consultation, you can indicate that in the form below. You will just be charged for one consultation fee, but will still be responsible for any costs associated with the vaccine.
- Please note- medication for malaria prevention is often recommended for travel to many countries. We will go over the recommendation with you, but we do not have a provider on staff who can write a prescription for malaria prevention. If needed, your primary care provider or other physician would need to write a prescription for the medication.
Appointment Scheduling

Gibbs Pharmacy will reach out to you via phone call within 1-2 business days to schedule an appointment once you have submitted this form.
Traveler Information and Demographics
Traveling Patient Name*

First NameLast Name
Traveling Patient Date of Birth*

MonthDayYear
Date
Traveling Patient Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Traveling Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload a photo of your prescription and medical insurance cards (if applicable):

Cancelof
Patient Sex*

MaleFemale
Where will you be traveling? Please list all cities and countries. *
Please select your reason for travel:*

BusinessLeisureVolunteeringOther
What areas will you be staying in?*

Rural (more remote areas)Urban (bigger cities)Other
When are you leaving for your trip?*

MonthDayYear
Date
How long will you be traveling?*
Do you know of any required immunizations you need before traveling?*

YesNo
What required immunizations were you told you needed?*

Screening Questions*

	Yes	No	I Don't Know
Do you have any chronic medical conditions? (kidney or liver disease, diabetes, etc.)
Do you have any drug allergies?
Do you have a severe allergy to eggs?
Do you have any immunocompromising conditions?
Do you expect to come in contact with animals on your travels?
Have you traveled internationally before?

Please tell us any other information you'd like us to know, or questions you would like us to help answer:
How did you hear about our travel health services?
Please bring a copy of your vaccine records or immunization card if you have that available. Thank you!
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Travel Consult and Yellow Fever Vaccine Appointments

Appointment Scheduling

Traveler Information and Demographics