Travel Vaccines
Please complete this form to prepare for your pre-travel consultation with our GLCP pharmacist to determine what vaccines are necessary for your upcoming international trip.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
Confirmation Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Departure
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
What is the date scheduled to leave for the international trip?
Date of Return
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
What is the date scheduled to return home from the international trip?
What is Your Destination Including Layover Destinations?
*
If you prefer to upload your itinerary, please do so below.
What is Your Expected Trip Itinerary?
*
If you prefer to upload your itinerary, please do so below
Itinerary Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Primary Care Physician's Name
*
Please enter the FULL NAME of your primary care physician
Primary Care Physician's Number
*
Please enter a valid phone number of your primary care physician
Format: (000) 000-0000.
Do You Have Any Drug Allergies?
*
Yes, please list below
No
List Drug Allergies Here
Please Provide a List of Current Medications, Including Over-the-Counter Medications Like Vitamins
*
If You Do Not Take Medications Please Type "None" Above
Please Provide Your Vaccination History
*
If You Prefer to Upload your Vaccination History, Please Type That You Will Be Doing so Below and Upload That File Upload, "Vaccination History Upload".
Vaccination History Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do You Have Any Significant Medical Conditions?
*
YES, please list below
NO
Medical Conditions
If you clicked "YES" above, please list your significant medical conditions here. If you clicked "NO" above simply type "None" here.
What Are Your Plans for Accommodations?
*
Staying with local/native people
Staying in hotels with air conditioning and filtered water
Going on safari
Camping in the bush
OTHER: Please List Plans Not Listed Here In The Space Provided Below
Accommodations Not Listed Above
Please describe international travel accommodations here so our pharmacists can provide you the best guidance.
Do You Have Plans For Any High Altitude Activities? (Mountain Climbing, etc.)
*
Yes
No
Do You Have Plans To Eat Local Foods Or Any Adventurous Eating?
*
Yes
No
Have You Been Diagnosed With G6PD Deficiency?
*
Yes
No
Are You Pregnant or Planning on Becoming Pregnant?
*
Yes
No
Are You Breastfeeding or Will Be at The Time of Travel?
*
Yes
No
Submit
Should be Empty: