Travel Medicine

Travel Medicine
To schedule services to help you stay healthy during international travel, please complete and submit the form below:
Do you need language assistance (an interpreter)?
What language(s) do you speak?
Please specify the language you speak

LOCATION AND APPOINTMENT
Please select your preferred location to receive travel services:
*Clifton Springs is coming soon.

*Clifton Springs - 3110 Clifton Springs Rd. Suite D, Decatur, GA 30034
East DeKalb: Select an appointment date and time then click next
North DeKalb: Select an appointment date and time then click next
T.O Vinson: Select an appointment date and time then click next
Clifton Springs: Select an appointment date and time then click next

BASIC INFORMATION
Are you scheduling an appointment for a family?
For how many family members you are scheduling the appointment?
NOTE: For more than 2 family members additional forms will be completed in the clinic.

PATIENT TRAVEL CONSULTATION

PATIENT 1
Departure date from USA

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

Travel Itinerary

Rows	Country	Region	Date of arrival at destination (MM/DD/YYYY)	Departure date from destination (MM/DD/YYYY)	Length of stay at each destination (Days)
1
2
3
4
5

PATIENT TRAVEL CONSULTATION

PATIENT 2
Departure date from USA

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

Travel Itinerary

Rows	Country	Region	Date of arrival at destination (MM/DD/YYYY)	Departure date from destination (MM/DD/YYYY)	Length of stay at each destination (Days)
1
2
3
4
5

REGISTRATION FORM

PATIENT 1
Patient Name 1

First NameMiddle NameLast Name
Date of birth

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

Street Address

Street Address Line 2

CityState

Zip Code
Phone number
Email address
Emergency contact name
Emergency contact phone number
Format: (000) 000-0000.
Date of birth of emergency contact

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

FAMILY FORM
Patient Name 2

First NameMiddle NameLast Name
Date of birth Patient 2

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex Patient 2
Address (If different from person 1)

Street Address

Street Address Line 2

CityState

Zip Code
Patient Name 3

First NameMiddle NameLast Name
Date of birth Patient 3

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex Patient 3
Address (If different from person 1)

Street Address

Street Address Line 2

CityState

Zip Code
Patient Name 4

First NameMiddle NameLast Name
Date of birth Patient 4

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex Patient 4
Address (If different from person 1)

Street Address

Street Address Line 2

CityState

Zip Code
Patient Name 5

First NameMiddle NameLast Name
Date of birth Patient 5

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex Patient 5
Address (If different from person 1)

Street Address

Street Address Line 2

CityState

Zip Code

STATEMENT OF ACCURACY OF INFORMATION PROVIDED:
I understand that I am responsible for full payment of DeKalb Public Health fees by cash or debit/credit card at the time of service.
Patient, Parent or Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Consent for release of immunization information into the Immunization Registry - GA Registry of Immunization Transactions & Services (GRITS)

I authorize DeKalb Public Health to release any immunization information and/or documents containing such information to the GRITS database.
Consent for Photography: I consent for photographs to be taken of me or my child (or person for who I am the legal guardian). I understand that the information may be used in my medical record for the purposes of preventing identity theft. By consenting, I understand that I will not receive any payment. Refusal to consent will not affect the medical care I receive.
Patient, Parent or Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Additional comments:

Rows	Type your answer
Date of your last menstrual period:
Method of birth control:

Rows	Type your answer
Date of your last menstrual period:
Method of birth control:

NURSE
Nurse's Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
CALL CENTER
Appointment Date Verification:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Approval Status
Call Center Representative
Date Entered into My Insight

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Time Entered into MyInsight

Hour Minutes

AM/PM Option
Reschedule or Cancellation Reason
Original Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
New Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Comments
Review and Submit

To review this form, click Back. To submit this form and book your appointment, click Submit.
Should be Empty:

Rows	Yes	No	Problems
Have you ever fainted from having your blood drawn or from an injection?
Have you ever had a fever from vaccination?
Have you ever had any bad reaction/side effect from any vaccination?
Have you had hepatitis A vaccine?
Have you had hepatitis B vaccine?
Do you live (or work closely) with anyone who has AIDS or other immune disorder or who is on cancer chemotherapy?
Have you received an injection of immune globulin or any blood product in the past 8 months?

Rows	Yes	No	Problems
Do you have a medical condition that requires medication or physician follow-up?
Do you have a medical condition that is stable now but that may recur while traveling?
Have you had a fever in the past 48 hours?
Do you have AIDS, any other immune disorder, or cancer?
Do you have severe thrombocytopenia (low platelet count) or a clotting disorder?
Have you ever had a convulsion, a seizure, or epilepsy?
Do you have any stomach or/and intestinal problems?
Have you ever had hepatitis or yellow jaundice?
Do you have a history of psychiatric or emotional problems?
Do you have a problem with strange dreams and/or nightmares?
Do you have psoriasis?

Rows	Yes	No	Problems
Are you pregnant or might you become pregnant on this trip?
Are you breastfeeding?
Do you have problems with vaginitis?
Are you on hormone replacement therapy?

Rows	Yes	No	Problems
Quinine, quinidine, or medication for a heart conduction problem?
Prednisone, cortisone or another steroid?
Antibiotics?
Pepto-Bismol?
Another antacid?

SERVICES AND FEES