Travel Clinic Registration

Name

First

Last

Date of Birth

Email

Cell Phone

Other Phone

Do you have a private Insurance Plan?

Yes

No

Let us know your insurance company and your policy number, we will see if the cost of your vaccination is covered by your insurance plan.

Insurer's name:

Policy Number

Country of destination

City

Have you traveled to this country in the past?

Yes

No, this is my first time

How long ago?

Will you be visiting another country/region during your trip?

Yes

No

Please, list all countries and regions you will visit (including stop over) during your trip:

Please specify the type of your trip:

Staying with family/Relatives

Affluent Travel in a quality hotel

Business travel in an urban area

Travel in rural or remote areas

Backpacking or trekking in mountains/jungles

OtherOther

I confirm that I am submitting this application for:

Myself

Someone other than myself

I confirm that I am the applicant's

Parent

Legal guardian

Substitute decision maker

Name

First

Last

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