Kroger Pharmacy Travel History Form
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4TRAVEL HISTORY FORM
Upon completion of this form please call your Kroger Pharmacy to set up an appointment
Please complete as much detail as possible to help the pharmacist best prepare you for your upcoming trip
PATIENT INFORMATION
Name:
______________ Date:
______
Address:
City:
State:
Zip:
Date of Birth:
/
/
Male
Female
E-Mail Address: _
_____________
Home Telephone no.: __________
_________
Cell Phone:
Do you have a current passport?
Yes
No
I Don’t Know
Are you visiting a country that requires a visa?
Yes
No
I Don’t Know
Have you already obtained a visa?
Yes
No
I Don’t Know
TRAVEL SPECIFICS
Purpose of Trip:
School Related Study/Work What Program?
Pleasure
Business
Other:
What will you be doing on this trip? _____________
______
__________________________________________________________________________________________________
Who else will be travelling with you? ___________________________________________________________________
Does your program require the completion of a medical form by a practitioner?
Yes
No
Are you currently enrolled in a health insurance plan that covers you while overseas?
Yes
No
What insurance coverage do you currently have (please bring your PRESCRIPTION insurance card, or a copy when
turning this form in)?
Do you have medical evacuation insurance?
Yes
No
Departure date from United States: _
/
/
Return date to United States: _
/
/
Countries AND cities to be visited in order of visits
Arrival Date
Departure Date
Have you traveled outside the United States before?
Yes
No
If yes, where and when?
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“The information contained in this communication may be privileged and confidential and may be protected from disclosure. If the reader of this message is not the intended recipient, or an employee or
agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have
received this communication in error, please notify us immediately.”
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