Travel Medicine and Immunization Service

In order to provide for the best use of the time allotted in your travel medicine appointment, please complete and submit the following information 48 hours in advance of your appointment. Thank you! Health History and Travel Itinerary:

Fields marked with an asterisk* are required.

Medical History

Chronic Illnesses

Other Chronic Illnesses

Major Surgery

Medications

Allergies

Prior Travel Immunizations Received

Travel Itinerary

For the following, please include country, region and town if known