Travel Consultation Information

Travel Consultation Information

A travel consultation includes vaccine recommendations based on your history and destination, contacting your doctor for any needed prescriptions, and education about travel health. The consultation fee is in addition to any copays for medications or vaccines. The yellow fever vaccine requires a $50 fee in addition to your copay. The pricing tiers are listed below. We require a minimum of 10 days before your trip to make your request for a travel appointment, and generally recommend contacting us 4-6 weeks prior to travel. Please submit a form for every person that will be traveling on the trip. You should receive a text message within 72 business hours to let you know your request has been received. Thank you for choosing Bremo Pharmacy for your travel needs!
Tier 1: Single Person- $75

Tier 2: Couples- $125

Tier 3: Families

Families with no children/children over the age of 18- $150

Families with children under 18- $175
Name*

First NameLast Name
If 18 years or younger, name of parent/guardian

First NameLast Name
Gender Assigned at Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Primary Care Physician *

First NameLast Name
Primary Care Phone Number
Please enter a valid phone number.
Please upload insurance information

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Medical Conditions (check those that apply):*

AsthmaCancerChronic BronchitisCOPDCongestive Heart FailureCirrhosis of the LiverDiabetes (type 1 or type 2)Heart DiseaseHIV infectionImmune DeficiencyOrgan TransplantSplenectomy/ inactive spleenSickle Cell DiseaseTuberculosis (untreated)None of these medical conditions
Current Medications:
During the the past 3 months, have you taken:*

Oral steroidsChemotherapyRadiation TherapyNone of the above
Please list any allergies:
If 18 years or younger, how much does the child weigh?
What countries are you traveling to? *
What cities, provinces, parks, etc will you be traveling to? Please list as much detail as possible and include dates in each location.*
Do you have any layovers?*

YesNo
List all layovers and duration
What date are you leaving?*

MonthDayYear
Date
What date are you returning?*

MonthDayYear
Date
What types of activities? (Safari, mission work, working with animals, etc.)*
Select all types of lodging you will use on your trip*

HotelStaying with friends/familyCampingHostelOther
If "Other" please specify:
Do you plan to have contact with animals?*
Please provide more details
Are any of your destinations at elevation? (over 8,000 feet above sea level?)*
Please provide locations and number of days at each location
What is your weight (in pounds)? This will be used to dose your medication
Is there any other information we need to know to complete your travel consult?
Are you traveling with a group or another person that is submitting for a travel consult, if so what is their name?
If any other members of your group also want a travel consult please submit another form for each person
By signing below, you agree to pay the consultation fee based on the appropriate tier in addition to any copays for vaccines or travel medications.*

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