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Travel Consultation Interest Form

HIPAA

Compliance

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    If you know what travel vaccines you are needing and wanting to book a vaccine appointment, please use our immunization appointment scheduler instead. This form you are about to complete is intended for a travel consultation with a pharmacist. Consultation fees may apply.

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    *** PLEASE READ THIS IN ITS ENTIRETY ***

    Our pharmacists are trained to provide a full consultation, including an assessment of your health and instructions on how to minimize the risk of travel so you can enjoy your trip fully.  We have the ability to administer vaccinations required for travel.  We will work with your primary care provider to obtain medications to prevent and/or treat travel-related conditions such as malaria, diarrhea, altitude sickness and motion sickness.

    We highly recommend you to sign up for travel consultation at least 4 weeks prior to your travel to allow enough time for your body to develop immunity from the required vaccines.

     

    Terms and conditions:

    -We provide travel consultation to patients 12 years of age and above, without high risk for anaphylaxis for any needed vaccine administration prior to travel.

    -You are required to schedule and attend a full consultation in order for our pharmacists to evaluate your vaccination requirement for your travel.  Abbreviated consultations for persons who have had a full consult with us previously and are traveling to the same/similar area may be available.

    -You acknowledge that you have received a copy of our privacy practices and clinic policy.  

    -You consent to treatment and billing of services.  

    -The consultation fee is $125 per person. This fee does NOT include costs of vaccinations and medications recommended/required for your travel. 

    -A booking fee of $25 is required to schedule an appointment, this fee will be credited towards your consultation fee.

    -You may be subject to a cancellation fee if you cancel within 72 hours prior to your appointment.

    -After reviewing your Pre-Travel Intake Form and prior to your visit, if the pharmacist determines that you need to see a specialist practitioner for your consult, then the pharmacy will notify you as soon as possible and you will be refunded the consultation fee.  However, if a full evaluation has been started and referral is recommended in addition to your visit with us, no refunds are available.

    -Each travel companion is subject to their own consultation appointment and fee.

    -You agree to fill out the Pre-Travel Intake Form and provide this to the pharmacy at least 1 week prior to your appointment in order to allow time to provide you the best information available and to ensure all vaccinations required are in stock at the time of appointment.

    -If you need travel or health-related forms to be completed during your visit, you will bring these forms with you to the visit. 

    -You must allow time for a full consultation, up to 30 minutes, and an additional 15 minutes after any vaccination adminstration to monitor for signs of severe allergic reaction. 

    -You understand that prevention is not a guarantee of freedom from ailment, and you agree to see primary care provider and discuss your travel if you have an infection occuring days to months upon your return

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    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    Please list, in order, the countries/cities you plan to visit. Indicate the month of travel and number of days you will spend in each country. Example: 1. Japan/Tokyo/April/5 days 2. Korea/Seoul/May/4 days
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    Select each travel category applicable to your trip
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    Select all that apply to you
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    By signing here, I acknowledge that I have read and consent to the above Terms and Conditions of the Travel Consultation
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    All information is confidential and is accessed only via a secure, encrypted interface.

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