Clair Medical Travel Clinic Consultation Form
Please complete this form prior to your travel consultation appointment with your pharmacist. During the appointment, your pharmacist will review the information provided and may recommend appropriate vaccines and medications to help you stay healthy.
All individuals for whom the appointment has been booked, including any dependent(s), must complete the Travel Consult Form before the appointment. After submitting the form for the first individual, you will be given the option to complete it for additional individuals.
Customer Details:
Please provide your personal information in the fields below. If you are completing this form on behalf of any dependent(s) for whom you have consent, kindly include their information as well. Fields marked with an asterisk (*) are required.
Full Name
*
First Name
Last Name
Phone Number
*
E-mail
example@example.com
E-mail 2
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Card Number & Version Code
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Other
Select Which Applies to You:
*
Pregnant
Breast-feeding/Chest-feeding
None of the Above
Weight (in kg)
*
Height (in cm)
*
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Trip Information:
Please enter the details of the country you are visiting. If your trip includes more than one country, including any stopovers, provide details for each country separately. Use the “Add Country” button to open additional fields.
Country
*
City/Region
*
Arrival Date
*
-
Month
-
Day
Year
Date
Departure Date
*
-
Month
-
Day
Year
Date
Will You Visit a Rural Area?
*
Yes
No
Unsure
Do You Anticipate Getting Motion Sickness on This Trip?
*
Yes
No
Unsure
What Type of Accommodation Will You Be Staying In?
*
Hotel/Resort
Camp
Budget Hotels/Hostels
Company Lodge
Inns/AirBnB
Family/Friends
Cruise Ship
Other
What Type of Activities Are You Planning To Do?
*
Eat at Local Resturants/Bars
Extreme Sports
Healthcare/Volunteer Activities
High Altitudes
Contact with Animals
Excursion off Resorts
Swimming
Other
Do You Want to Add Another Country?
*
Yes
No
Country
*
City/Region
*
Arrival Date
*
-
Month
-
Day
Year
Date
Departure Date
*
-
Month
-
Day
Year
Date
Will You Visit a Rural Area?
*
Yes
No
Unsure
Do You Anticipate Getting Motion Sickness on This Trip?
*
Yes
No
Unsure
What Type of Accommodation Will You Be Staying In?
*
Hotel/Resort
Camp
Budget Hotels/Hostels
Company Lodge
Inns/AirBnB
Family/Friends
Cruise Ship
Other
What Type of Activities Are You Planning To Do?
*
Eat at Local Resturants/Bars
Extreme Sports
Healthcare/Volunteer Activities
High Altitudes
Contact with Animals
Excursion off Resorts
Swimming
Other
Do You Want to Add Another Country?
*
Yes
No
Country
*
City/Region
*
Arrival Date
*
-
Month
-
Day
Year
Date
Departure Date
*
-
Month
-
Day
Year
Date
Will You Visit a Rural Area?
*
Yes
No
Unsure
Do You Anticipate Getting Motion Sickness on This Trip?
*
Yes
No
Unsure
What Type of Accommodation Will You Be Staying In?
*
Hotel/Resort
Camp
Budget Hotels/Hostels
Company Lodge
Inns/AirBnB
Family/Friends
Cruise Ship
Other
What Type of Activities Are You Planning To Do?
*
Eat at Local Resturants/Bars
Extreme Sports
Healthcare/Volunteer Activities
High Altitudes
Contact with Animals
Excursion off Resorts
Swimming
Other
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Medical History
Please provide information about your medical history. Fields marked with an asterisk (*) are required.
Do You Have or Have You Ever Had Any Chronic Illness or Medical Condition(s)?
*
Yes
No
If Yes, Please List the Condition(s):
Are You Currently Taking Any Prescription and/or Over the Counter Medication(s)?
*
Yes
No
If Yes, Please List the Medication(s)
Do You Have Any Allergies
*
Yes
No
If Yes, Please List the Type of Allergy & the Description of Your Allergic Reaction
Have You Ever Had Travel Vaccinations in the Past 10 Years?
*
Yes
No
Unsure
If Yes, Please List the Name of Vaccines, the Date Received & Any Serious Reaction You Had to the Vaccine
Submit
Should be Empty: