Pre-Travel Form

The Pre-Travel Form must be filled out prior to your appointment with Travel Health Services.

This information will help us choose the best vaccinations and recommendations for your journey.

You may complete the Pre-Travel Form on-line and it will be sent to our office.

You may also download and print the form. If you print the form, be sure to bring the completed copy to your appointment.

Print Pre-Travel Form

  • Personal Data

  • Date Format: MM slash DD slash YYYY

  • Travel Information

    List all travel dates and countries in order of dates travelling:

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • If Yes:

  • Medication and Allergy Information

  • Please check if allergic to any of the following medications:
  • Please check if allergic to any of the following vaccine components:
  • Please check if allergic to any of the following:
  • Previous Immunizations or History of the Disease Type "c" for childhood series completed, or enter year vaccinated or ill.

  • The above information is accurate to the best of my knowledge. I understand that insurance may not cover travel immunization services and I am responsible for all fees due at time of service. Travel Health Services is not a Medicare provider and does no insurance or filing of claims. Payment is due at the time of service by credit card, cash or check. I understand that I will be given an immunization record with all vaccines received and that I am responsible for keeping this in a safe place and keeping records up to date. Inactive records are kept on file for 3 years. Your files are confidential.