Travel Clinic Screen Form printable pdf download

Travel Clinic Screen Form

Tulalip Clinical Pharmacy 8825 34th Avenue NE, Suite A, Tulalip, WA 98271 360-716-2660

TRAVEL CLINIC SCREEN FORM

Please fax completed form to

360-716-3660

Date

:__________________

Demographics

Traveler: __________________________________________________________

Phone (_________)__________________

Last

First

Address: ________________________________________________________ City: ______________________ Zip: ________________

DOB _____/_____/_____

Weight in lbs (for children under 12) _________

Gender: ___ M ___ F

Insurance Information

- Tulalip Clinical Pharmacy can bill your prescription (not medical) insurance

Insurance Name: ______________________________________________________

Bin#:________________________________________

PCN#:______________________________________________

RX Group#:______________________

ID#:____________________________

Person Code: ___________

Coverage: Self______ Spouse______ Dependent______ Other______

Trip information

Date of departure _____/_____/_____

Date of return _____/_____/_____

Itinerary (*please list countries in sequence of arrival and include layovers):

Country/Cruise

Region/City

Duration

Medical Information

Do you have any allergies to medications, foods, vaccines or insect bites?

___ No

___ Yes:____________________________

Current prescription medications

Over-the-counter medications

Travel Clinic Screen Form