ADDITIONAL TRAVELER FORM

Additional International Traveler Vaccine Appointment Form

Only complete this form if you share the same travel itinerary as your trip leader and plan to attend the same appointment time.
¿Hablas español?

Presione la bandera en la esquina superior derecha y cambie a español.
🌍✈️ International Travel Vaccine Appointment

All travel vaccine appointments are 60 minutes include:

🗺️ Itinerary Review – Advice based on where you’re going
🌡️ Health & Safety Info – Country-specific risks and tips
💉 Vaccines – Including Yellow Fever and others you may need
🦟 Malaria Prevention – We only recommend anti-Malarias and insect protection. Seek prescriptions with PCP if medications are recommended.
🤢 Travel Illness Tips – How to avoid common issues
📄 Handouts – Easy-to-follow country info & travel advice
Trip Leader
Trip Leader's Full Name*
Trip Leader's Birthdate *

MonthDayYear
Date
Date of Travel Consultation

MonthDayYear
Date

Patient Demographics
Patient name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Patient Age*
If under 1 year of age, please enter 0.
What is your sex assigned at birth?*
What is your gender?
Language spoken at home*
Language
What is your race?
What is your ethnicity?
Contact Information
Email*
A confirmation of your appointment will be sent to the email address entered above.
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Voice Mail/TextEmailMailNo Calls

Cost of Travel Consult and Vaccinations

Please read the following information and indicate that you understand the cost of the travel consult and vaccinations.
- Patients are required to pay for travel immunizations at the time of their consultation. We will bill your insurance on your behalf; however, travel vaccines may not be covered by all insurance plans. If your insurance does pay, we will reimburse you for the amount covered.
Vaccine Price List: https://www.healthygallatin.org/wp-content/uploads/2025/09/VaccinationsPricingList_09112025.pdf
Yes, I understand and agree to pay.No, I do not understand. Please contact me for more information.

Health Insurance Information
YesNo
Insurance Company Name*
Member ID Number*
Group Number*
(Type "none" if one is not listed)
Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Relation to Client*
Health Insurance Card

If you're able, please take a photo of the front and back of your insurance card or upload a digital copy
Front of card
Back of card
Upload a digital copy of your insurance card

Cancelof

Billings Practices Acknowledgement
Yes, I understand the biling information.No, I don't understand the billing information and would like to speak with a billing specialist.

Vaccines Requested
Vaccines for school attendance (such as DTap/TDap, MMR, varicella, polio)Routine vaccines for age (such as Hepatitis A/B, TDap, HPV)International travel vaccines (such as Yellow Fever, Typhoid, Rabies)COVIDFlu

Important Information - Please Read Before Continuing
Before selecting any vaccines, you are required to review the Vaccine Information Statements (VIS) and/or Emergency Use Authorization (EUA) fact sheets for the vaccine(s) you may receive. These documents explain:
- The disease(s) the vaccine(s) prevent
- The risks and benefits of the vaccine(s)
- Possible side effects and what to expect after vaccination
It is your responsibility to review this information so you can make an informed decision about vaccination.

The following page will include the statements and include an acknowledgement question.

Immunization Records
YesNo
Please upload your immunization records here

Cancelof
YesNo
Tips for Locating Old Immunization Records

Post-Vaccination Observation Acknowledgement
The patient agrees to wait 15 minutesThe patient declines to wait 15 minutes

Patient Privacy Practices
Please review our Notice of Patient Privacy Practices: Notice of Privacy Practices
YesNo

Consent for Services
Yes, I consent to the shared use of demographic information and authorize my immunization records to be recorded into the State of Montana Immunization Registry for immunization health purposes and that it may be released to health care providers, childcare providers and schools across the state that may provide continuing immunization services. I understand that I can revoke this authorization and have my record removed at any time by contacting my local county health department.No, I do not consent to the above statement.
I give permission for my child's school to release the following information concerning my child to the Gallatin-City County Health Immunization Program: Name, Date of birth, Immunization history, Parent/guardian contact information. The school and the Immunization Program will collaborate and use this information to: review your child's immunization history, notify you if immunizations are due for school attendance, and provide opportunities to vaccinate your child at local or school-based clinics. This consent will be in effect as long as your child is enrolled in this school system and can be reversed at any time by sending a written note to your child's school.No, I do not consent to the above statement.N/A - I am not a K-12 student.
By signing this form, I am requesting vaccination services for myself and/or the persons identified, of whom I am authorized to sign. A copy of the appropriate Centers for Disease Control and Prevention Vaccine Information Statement(s) or Emergency Use Authorization(s) has been provided. I have read the information about the disease(s) and the vaccine(s) listed. I believe that I understand the benefits and risks of the vaccine(s) cited and ask that the vaccine(s) listed be given to me or to the person named (for whom I am authorized to make this request).
Patient (over age 18) or Parent/Guardian - Please sign your name here*

Clear
If you are unable to sign your name, please type your name below

First NameLast Name
Today's Date

MonthDayYear
Date
Relationship to Patient*
Comments, questions, or concerns:
Should be Empty:

Additional International Traveler Vaccine Appointment Form

Trip Leader

Patient Demographics

Contact Information

Cost of Travel Consult and Vaccinations

Health Insurance Information

Health Insurance Card

Billings Practices Acknowledgement

Vaccines Requested

Important Information - Please Read Before Continuing

Vaccines Requested

Acknowledgement Questions

Immunization Records

Post-Vaccination Observation Acknowledgement

Patient Privacy Practices

Consent for Services