TRAVEL CONSULT APPOINTMENT FORM 2026

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
- Last Minute Travelers are subject to increased fees due to limited availability and expedited planning needs.
- 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.
Review our Vaccine Price List HERE
🌍✈️ 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
I have read and agree to pay the cost of the travel consult & vaccinations.

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.
Which day(s) of the week would you prefer?
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
2 digit month, 2 digit day, 4 digit year
Patient Age
If under 1 year of age, please enter 0.
Patient sex assigned at birth
Patient gender
Language spoken
Language
Will you need an interpreter at your consultation?
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
Contact Preference

How many people would like to be scheduled within the same appointment time for a travel consult?

Do you share the same itinerary?
🛫 If all travelers are following the same itinerary, only one person (trip leader) should complete this form.

Once you finish this form, please have each additional traveler complete the Additioinal Traveler Form. The link will be provided on the Thank You page and again in your confirmation email for each additional traveler to complete.

⚠️ 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
Do you have health insurance?
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
2 digit month, 2 digit day, 4 digit yearDate
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

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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
I understand that I am responsible for any charges not covered by insurance, state programs, grant programs, or other funding sources. If applicable, I understand that my charges will be billed according to the sliding scale fee based on my income. I authorize payment of medical benefits to the county health department for the services provided.

Vaccines Requested
Vaccine(s) requested

Other

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
Do you have access to a copy of your immunization records? (screenshots or paper documentation)
Please upload your immunization records here

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Would you like us to contact you for additional support to locate and compile your immunization records?
Tips for Locating Old Immunization Records

Post-Vaccination Observation Acknowledgement
For your safety, we recommend that everyone who gets a vaccine stays for 15 minutes. This short wait helps us respond quickly in case of fainting or an allergic reaction.

Patient Privacy Practices
Please review our Notice of Patient Privacy Practices: Notice of Privacy Practices
I have reviewed the Notice of Privacy Practices, which provides a description of information uses and disclosures.

Consent for Services
Consent for imMTrax

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.
Release of Immunization Information Consent for K-12 Students

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.
Consent for Vaccination - You Must Sign This to be Vaccinated

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

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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

Rows	Country	Region	Urban/Rural	Accommodations	Arrrival Date	Departure Date
Destination 1
Destination 2
Destination 3
Destination 4
Destination 5

Travel Consult Appointment Form

Appointment Request

Patient Demographics

Contact Information

🕒 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.

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