Travel Consultation Information with Group Option

Travel Consultation Information

A travel consultation includes vaccine recommendations based on your history and destination, contacting your doctor for any needed prescriptions, and education about travel health. The consultation fee is in addition to any copays for medications or vaccines. The pricing tiers that are listed below include a $10 non-refundable deposit to secure your travel consult appointment. If you require a yellow fever vaccine for travel, there will be an additional $50 administration fee in addition to your copay for the vaccine. We require a minimum of 10 days before your trip to make your request for a travel appointment, and generally recommend contacting us 4-6 weeks prior to travel. You should receive a text message within 72 business hours to let you know your request has been received. Thank you for choosing Bremo Pharmacy for your travel needs!
Tier 1: Single Person- $75

Tier 2: Couples- $125

Tier 3: Families

Families with no children/children over the age of 18- $150

Families with children under 18- $175

*A $10 non-refundable deposit will be applied to cost for each tier
What countries are you traveling to? *
What cities, provinces, parks, etc will you be traveling to? Please list as much detail as possible and include dates in each location.*
Do you have any layovers?*

YesNo
List all layovers and duration
What date are you leaving?*

MonthDayYear
Date
What date are you returning?*

MonthDayYear
Date
What types of activities? (Safari, mission work, working with animals, etc.)*
Select all types of lodging you will use on your trip*

HotelStaying with friends/familyCampingHostelOther
If "Other" please specify:
Do you plan to have contact with animals?*
Please provide more details
Are any of your destinations at elevation? (over 8,000 feet above sea level?)*
Please provide locations and number of days at each location
Is there any other information we need to know to complete your travel consult?
Name*

First NameLast Name
Gender Assigned at Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Is the traveler under 18 years old?
How much does the child weigh?
Primary Care Physician *

First NameLast Name
Primary Care Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please upload insurance information

Cancelof
Medical Conditions (check those that apply):*

AsthmaCancerChronic BronchitisCOPDCongestive Heart FailureCirrhosis of the LiverDiabetes (type 1 or type 2)Heart DiseaseHIV infectionImmune DeficiencyOrgan TransplantSplenectomy/ inactive spleenSickle Cell DiseaseTuberculosis (untreated)None of these medical conditionsOther
Current Medications:
During the the past 3 months, have you taken:*

Oral steroidsChemotherapyRadiation TherapyNone of the above
Allergies*
Type "NA" if none

Vaccine History- provide as much detail as you can or upload a picture below

Rows	Received?	Approximate Date(s) Received
Hepatitis A
Hepatitis B
Yellow Fever
Typhoid
Tdap
Meningitis
Flu
COVID-19

Upload vaccine records

Cancelof
What is your weight (in pounds)? This will be used to dose your medication
Are you traveling with another person that will also need a travel consult?
Additional Traveler:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Is the traveler under 18?
How much does the child weigh?
Gender Assigned at Birth*
Primary Care Physician *

First NameLast Name
Primary Care Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Conditions (check those that apply):*

AsthmaCancerChronic BronchitisCOPDCongestive Heart FailureCirrhosis of the LiverDiabetes (type 1 or type 2)Heart DiseaseHIV infectionImmune DeficiencyOrgan TransplantSplenectomy/ inactive spleenSickle Cell DiseaseTuberculosis (untreated)None of these medical conditionsOther
Current Medications:
During the the past 3 months, have you taken:*

Oral steroidsChemotherapyRadiation TherapyNone of the above
Allergies*
Type "NA" if none

Upload vaccine records below

Cancelof
What is the traveler's weight in pounds?
Do you need to add any additional travelers?
Additional Traveler:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Is the traveler under 18 years old?
How much does the child weigh?
Gender Assigned at Birth*
Primary Care Physician *

First NameLast Name
Primary Care Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Conditions (check those that apply):*

AsthmaCancerChronic BronchitisCOPDCongestive Heart FailureCirrhosis of the LiverDiabetes (type 1 or type 2)Heart DiseaseHIV infectionImmune DeficiencyOrgan TransplantSplenectomy/ inactive spleenSickle Cell DiseaseTuberculosis (untreated)None of these medical conditionsOther
Current Medications:
During the the past 3 months, have you taken:*

Oral steroidsChemotherapyRadiation TherapyNone of the above
Allergies*
Type "NA" if none

Upload vaccine records below

Cancelof
Do you need to add any additional travelers?
Additional Traveler:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Is the traveler under 18 years old?
How much does the child weigh?
Gender Assigned at Birth*
Primary Care Physician *

First NameLast Name
Primary Care Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Conditions (check those that apply):*

AsthmaCancerChronic BronchitisCOPDCongestive Heart FailureCirrhosis of the LiverDiabetes (type 1 or type 2)Heart DiseaseHIV infectionImmune DeficiencyOrgan TransplantSplenectomy/ inactive spleenSickle Cell DiseaseTuberculosis (untreated)None of these medical conditionsOther
Current Medications:
During the the past 3 months, have you taken:*

Oral steroidsChemotherapyRadiation TherapyNone of the above
Allergies*
Type "NA" if none

Upload vaccine records below

Cancelof
Do you need to add any additional travelers?
Additional Traveler:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Is the traveler under 18 years old?
How much does the child weigh?
Gender Assigned at Birth*
Primary Care Physician *

First NameLast Name
Primary Care Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Conditions (check those that apply):*

AsthmaCancerChronic BronchitisCOPDCongestive Heart FailureCirrhosis of the LiverDiabetes (type 1 or type 2)Heart DiseaseHIV infectionImmune DeficiencyOrgan TransplantSplenectomy/ inactive spleenSickle Cell DiseaseTuberculosis (untreated)None of these medical conditionsOther
Current Medications:
During the the past 3 months, have you taken:*

Oral steroidsChemotherapyRadiation TherapyNone of the above
Allergies*
Type "NA" if none

Upload vaccine records below

Cancelof

Travel Consultation Deposit**

$10.00 Travel Consultation Deposit

Non-Refundable

$10.00 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

By signing below, you agree to pay the consultation fee based on the appropriate tier in addition to any copays for vaccines or travel medications.*
Should be Empty: