Please fill out, print,
and bring this
form to your Travel Consultation Appointment. This information will
be used to assess your health needs prior to your travel. Also bring your
Purpose of Trip:
Length of Stay:
Type of Accommodations:
Are you enrolled in a health insurance plan that covers you while overseas?
Does your program require the completion of a medical form?
Have you traveled outside the United States before?
If yes give the names/dates of travel immunizations received.
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