TRAVEL CONSULT APPOINTMENT FORM 2026

Travel Consult Appointment Form

Appointment Request

Patient Demographics

Contact Information

⚠️ If travelers do NOT share the same itinerary, each person must complete this form entirely.

Pre-Travel Assessment Form

Health Insurance Information

Health Insurance Card

Cost of Routine Vaccinations

Billing Practices Acknowledgement

Vaccines Requested

Important Information - Please Read Before Continuing

Vaccines Requested & Vaccine Information Statements

Acknowledgement Questions

Immunization Records

Post-Vaccination Observation Acknowledgement

Patient Privacy Practices

Consent for Services

⚠️ Note: Each additional traveler will need the trip leader's name and birthdate.

🕒 All individuals listed under the same trip leader will be seen during the same appointment.

Travel Consult Appointment Form
International travel appointments must be scheduled at least 4 weeks before departure to allow time for recommended vaccines to take effect and to coordinate any necessary prescriptions with your healthcare provider.
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- Cost of Travel Consult and Vaccinations
Please read the following information and indicate that you understand the cost of the travel consult and vaccinations.

Travel Consultation Fees

Starting in 2026, our travel consult prices will be updated to better reflect the time and care invovled in reviewing each traveler's unique itinerary and vaccine needs. We appreciate your understanding as we continue to provide thorough, high-quality travel health service.
- There is a charge for travel immunizations and patients are responsible for covering the cost of vaccines received during their consultation.
- We bill insurances, however travel immunizations may not be covered by certain insurance plans, therefore the patient is responsible for the balance if insurance payment is not received. We will reimburse the patient if insurance pays for the vaccine.
Vaccine Price List: https://www.healthygallatin.org/wp-content/uploads/2025/12/Flier_VaccinePriceList_12.11.2025.pdf
🌍✈️ International Travel Vaccine Appointment

All travel vaccine appointments include:

🗺️ Itinerary Review – Advice based on where you’re going
🌡️ Health & Safety Info – Country-specific risks and tips
💉 Vaccines Requirements – 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
Yes, I understand and agree to pay.No, I do not understand. Please contact me for more information.

Appointment Request
We have limited availability for travel consults on Mondays, Tuesdays, Thursdays and Fridays.

Please indicate your preferred day of the week and time of day.
Monday PM (1-4)Tuesday AM (8-12)Thursday AM (8-12)Thursday PM (1-4)Friday AM (8-1)
Comments about your scheduling preferences:
AFTER YOU'VE COMPLETED THIS FORM ONE OF OUR EMPLOYEES WILL CONTACT YOU TO SCHEDULE A DATE AND TIME.

Patient Demographics
Patient name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Patient Age*
If under 1 year of age, please enter 0.
Patient sex assigned at birth*
Patient gender
Language spoken*
Language
YesNo
Patient race*
Patient 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 MailSMS TextEmailMailNo Calls

1 person234More than 5

YesNo
🛫 If all travelers are following the same itinerary, only one person (trip leader) should complete the Pre-Travel Assessment Form.

Each additional traveler needs to complete this abbreviated form:

https://form.jotform.com/250986647266169. Feel free to share this link.

⚠️ Note: Each additional traveler will need the trip leader's name and birthdate.

🕒 All individuals listed under the same trip leader will be seen during the same appointment.
⚠️ If travelers do NOT share the same itinerary, each person must complete this form entirely.

Health Insurance Information
YesNo
Please note: Those with Medicare Part D plans will be asked to pay the patient portion not covered at the time of service.
Please note: If you do not have insurance, we have a state immunization program to cover the fees of the vaccine.Not all vaccines are included in this program. Any vaccines not covered by the program will need to be paid in full at the time of visit.
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. If you have Medicare, please include a copy of your red, white, and blue Medicare card.
Front of card
Back of card
Upload a digital copy of your insurance card

Cancelof

Cost of Routine Vaccinations
Vaccination Costs
- Travel-related vaccines are an additional cost and are due at the time of service. If your insurance later reimburses any portion, we will issue a refund to the original payee.
  - To view our current vaccine price list, visit: https://www.healthygallatin.org/wp-content/uploads/2025/09/VaccinationsPricingList_09112025.pdf
- International Certificate of Vaccination (Yellow Card)
  - The International Certificate of Vaccination or Prophylaxis (ICVP), commonly known as the "yellow card," is an official, internationally recognized document used to provide proof of vaccination for travel-related diseases.
    Replacement card: $10

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

Vaccines Requested
Routine vaccines for age (such as Hepatitis A/B, TDap, HPV)International travel vaccines (such as Yellow Fever, Typhoid, Rabies)COVID 2025-2026 vaccineFlu 2025-2026 vaccineOther

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
I agree (or agree on behalf of the person receieving the vaccine) to stay for 15 minutes after the vaccine.I prefer not to stay (or decline on behalf of the person receiving the vaccine).

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:

Rows	First Name	Last Name	Date of Birth	EMAIL or Contact #
Additional Traveler
Additional Traveler
Additional Traveler
Additional Traveler
Additional Traveler

Urban/Rural

Accommodations

Arrrival Date

Departure Date

Destination 1

Destination 2

Destination 3

Destination 4

Destination 5