If you are traveling abroad or overseas your destination may require that you receive a vaccine or medicine to prevent harmful viruses and diseases. Our urgent care center offers an array of Travel Vaccinations to ensure that you and your family are ready for your trip. We set up a customized immunization program based on the information you provide.

To save some time please fill out the travel vaccination questionnaire below and then book an appointment online.

Name

Sex

Date of Birth (MM/DD/YYYY)

Phone

Email

Your Destination

Dates of Tip

Purpose of your trip

Are you currently treated for any medical problems

Have you has a significant medical problem in the past

Could you be pregnant?

Are you staying mostly in cities/tourist destinations

Are you going to spend time in a rural area

Are you going to spend time above 5000 ft

Are you going to work in the foreign country

Are you allergic to eggs or chicken products

Have you has any hypersensitivity or reaction to vaccinations

Have you had Guillain-Barre Syndrome

Have you had all of your childhood vaccinations

Have you had tetanus/diphtheria vaccination in the last 10 years

Have you had measles vaccination (2 shots)

Have you had polio vaccination as an adult

Have you had hepatitis A vaccination (2 shots)

Have you had hepatitis B vaccination (3 shots)

Have you had meningitis vaccination in the past 3 years

Have you had typhoid vaccination in the past 2 yeats (if injected), or in the past 5 years (if oral)

Have you had yellow fever vaccination in the past 10 years

Have you had Japanese encephalitis vaccination in the past 2 years

List current or previous significant medical conditions

List current medications

Comments/Questions