Travel Health Pre-Appointment (NEW)

Before You Begin

This quick form helps us prepare for your travel health consult so your appointment is efficient and tailored to your itinerary. It takes about 5–10 minutes. Your information is kept confidential under applicable privacy legislation.

If you don’t have everything on hand, that’s okay—you can still fill out what you can and provide missing details later.

What You’ll Need
- Appointment details – preferred clinic location, full name, phone/email, and preferred date/time.
- Provincial health care number
- Drug/insurance & vaccination records – upload if available (or provide them by editing your submission later or by bringing them to your appointment).
- Health information – medical conditions, allergies, and current medications (name and dose).
- Travel plans – destinations (including layovers), arrival/departure dates and times, planned activities (e.g., hiking, rural stays), and accommodation type
- Helpful to have: past travel vaccines, drug insurance

Appointment Confirmation
Have you already booked an appointment?
Please Book an Appointment Through the Following Link Before Proceeding to Complete This Form

https://healthbox.ca/booking/travel-consultation/

Before proceeding, please confirm that the location, date, and time shown below match the details in your appointment confirmation email.

{servicingPharmacy86} - {appointmentType}

{pharmacyAddress}

{pharmacyPhone}

{pharmacyEmail}

Appointment Information

{appointmentBookingName}

{appointmentbookingDate}

{appointmentType}

IMPORTANT

Each individual will need to fill out their own form while also stating the appointment name and # of individuals attending the appointment when prompted. This helps us access and organize everyone's vaccine records ahead of time

Please share this link with other trip attendees that will be accompanying you to your appointment.

https://form.jotform.com/252998492948280

Take a Screenshot of the Following and Send it to the Other Attendees

Pharmacy Information

{servicingPharmacy86}

{pharmacyAddress}

{pharmacyPhone}

{pharmacyEmail}

Appointment Information

{appointmentBookingName}

{appointmentbookingDate}

Please upload a copy of any drug insurance plans you have

Ensure the following is captured in the photo: insurance provider name, cardholder name, client ID #, group ID, carrier ID
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Please use this to upload a copy of any travel vaccination records you have

Please feel free to use this to upload any travel vaccination records you may have in your possession - depending on where you received your vaccination, this may not be accessible in your provincial health record.
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Please answer the following general questions about your health.

	Yes/No	Additional Comments or Details
Do you have any allergies? (medication, environmental, food, etc.)
Do you have allergies to: Latex, Eggs/Chicken, or Adhesive Bandages?
Do you smoke or use nicotine products?
Were you immunized as a child?
Have you ever fainted or had an allergic reaction with Needles?
Have you had a tetanus shot in the last 10 years?
Have you ever taken medication to prevent malaria?
Have you ever previously received vaccinations for travel?
Have you had any vaccinations in the last 4 weeks?
Does the insurance information you provided apply to everyone attending the appointment?

Please list any prescription or non-prescription medications you take (skip to the next question if this doesn't apply)

	Medication/Over-the-Counter/Natural Health Product Name	Medication Type
1
2
3
4
5
6
7
8
9
10

Which of the following health condition(s) apply to you?

	Status
Diabetes
Emotional/psychiatric condition
Heart condition
Heartburn/acid reflux
High blood pressure
High cholesterol
Immune system  suppressed
Leukemia/Lymphoma/ recent cancer
Lung condition
Organ/bone marrow transplant
Pregnant or planning to become pregnant
Psoriasis
Recent chemotherapy or radiation (past 4 months)
Seizure disorder
Spleen removed

Plese confirm the details we have for your upcoming appointment

Appointment Information at {servicingPharmacy86} - {pharmacyAddress} - {pharmacyPhone} - {pharmacyEmail}

{appointmentBookingName}

{appointmentbookingDate}

{typeA138[8]}

# of People Attending: {typeA138[7]}

Your Information

{yourName}

{ltstronggtwhatsYour53}

{typeA138[2]}

{typeA138[3]}

{deliveryAddress60}

Trip Information

{ltstronggtgeneralTravel[1]}

{ltstronggtgeneralTravel[2]}

{ltstronggtpleaseProvide}

Appointment Confirmation