Travel Vaccine and Yellow Fever Consultation Form

Travel Consult and Yellow Fever Vaccine Appointments

Planning an international trip? Stay protected with our comprehensive travel health services. At The Clinic at Gibbs Pharmacy, we offer: Yellow Fever Vaccination, Travel Vaccines, Malaria Prevention, and comprehensive consultations for those who aren't sure what they need! Our trained pharmacists are here to provide expert advice, administer vaccines safely, and help you travel with peace of mind. Book your travel health consultation today!
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.
  - Pre-Travel Consultations are charged for all travel health appointments, including appointments inquiring about malaria prevention.
  - This is not a physical. If a pre-travel physical is required, we cannot provide that service.
- 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.
- We are not able to write a prescription for malaria prevention.
  - This can be prescribed by your primary care provider and filled at our pharmacy or your pharmacy of choice.
  - Malaria prevention is not a vaccine, it is a prescription medication.
- We can also provide you with medication for malaria prevention if recommended.
  - The cost varies based on the recommended medication for your travel location.
  - Only available for people 18 years and older. We recommend reaching out to your pediatrician for malaria prevention for those under 18 years old.
- 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.
Appointment Scheduling

If your preferred appointment day is unavailable, please call us at 615-657-5400 to see if we can accommodate. Thank you!
Appointment*
What type of service(s) would you like to discuss at your appointment?

Yellow Fever VaccineTyphoid VaccineTravel Vaccine Screening/RecommendationsOther
Traveler Information and Demographics
Traveling Patient Name*

First NameLast Name
Traveling Patient Date of Birth*

MonthDayYear
Date
Patients 60 years or older interested in receiving the Yellow Fever vaccine require a note from their physician stating that they are cleared to receive the vaccine. The vaccine cannot be administered without a note or prescription from your provider.

I acknowledge that I cannot receive the vaccine without approval from my provider.
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!
Should be Empty:

Travel Consult and Yellow Fever Vaccine Appointments

Appointment Scheduling

Traveler Information and Demographics