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Travelers Immunization Center

Notice Travelers Immunization Center does not accept insurance nor provide any insurance billing information due

to the high cost of vaccines and miserly insurance re-imbursement. You will receive a receipt for services tendered.

Name__________________________________Tel.____________________DOB___________

Address____________________________________ City, State, Zip _____________________

Personal Physician_______________________________________Tel.____________________

Travel Agent___________________________________________ Tel.____________________

Referred By____________________________________________________________________

Travel Destination_______________________________________________________________

Itinerary: Departure Date_________________________ Return Date_________________

Risk Assessment: Cruise__ Hotel__ Camping__ Living with Locals__ Safari__ Solo__

Healthcare/Volunteer__ Trekking__ Diving__ Rafting__ Spelunking__

Trekkers: Previous altitude problems, heart disease, lung disease? ________________________

Regular Medications_____________________________________________________________

Allergies: (eggs, vaccines, bees, food, medication)_____________________________________

Previous International Travel: _____________________________________________________

Previous Immunization/Year:

Tetanus/Diphtheria/Pertussis__ MMR__ Polio__ Varicella__ Flu__ Pneumonia__

Typhoid Oral__ Typhoid inject__ Yellow Fever__ Meningitis__ Hep A__ Hep B__ Japanese

Encephalitis__ Rabies__ TB skin test__ Zostavax__

Health problems: ______________________________________________________________

Pregnant_______________ Breast Feeding __________________

Vaccines, health precautions, insect protection and malaria prophylaxis are extremely helpful but do not guarantee

illness prevention. If you become seriously ill, it could be malaria. Seek local care or evacuation at once. Contact

your physician and Traveler’s immunization Center upon your return.

Medical Consent for Services: I understand that vaccines can in rare instances cause complications including death.

I also understand that the chance of serious harm is less that 1 in 1,000,000 and that these vaccines and medications

are FDA approved. I agree to accept the risk to decrease my chances of contracting a serious preventable disease. I

also give permission for you to provide my personal physician with the list of vaccines that I have received. I agree

not to seek re-imbursement from any insurance carrier for these services.

Signed_________________________________________ Date__________________

Traveler, Parent or Guardian