Travel Medicine Appointment Pre-screening Form
Please complete this pre-screening form to help us prepare for your upcoming travel medicine appointment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Travel Destination (Country/Region/City)
*
Departure Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Return Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purpose of Travel
*
Vacation
Business
Visiting Family/Friends
Study
Other
Have you reviewed your vaccination status for your destination?
*
Yes
No
Not Sure
Are you currently taking any medications?
*
Yes
No
Select your preferred appointment date and time
*
Submit Pre-screening
Should be Empty: