Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number *Date of Birth (dd/mm/yyyy): *Provincial health care number: *Please list your destination(s) of travel *What are your travel dates? *What types of accommodations will you be using? (please check all that apply) *Resorts/All InclusivesHotels/AirbnbsBackpacking/CampingOther or over-the-counter travel Will any of the following activities be included in your trip plans? (please check all that apply)Trying street foodsGoing to high altitudeHandling or close proximity to animalsSpending time in rural communities or farmsExposure to extreme heat or coldJungle/ForestOtherHave you had any serious reactions to a vaccine? *YesNoHave you had any any vaccines in the last month? *YesNoAre you currently taking any steroid medications? *YesNoAre you allergic to eggs, any antibiotics, or latex? *YesNoDo you or a family member have epilepsy? *YesNoDo you or does anyone in your household have a lowered immunity? *YesNoHave you experienced any of the following: *Jaundice/historyAllergiesCancer/ChemoDiabetesHeart DiseaseHIV/AIDSEar/Hearing ProblemsBlood ClotsPlease list all prescription or over-the-counter medications you are currently takingPlease list any medical conditionsPlease list any allergies (food or medications)Are your routine immunizations up-to-date? *YesNoUnsureHave you received any travel vaccinations in the past? *YesNoUnsurePlease list all travel vaccinations and date of administration (to the best of your ability)Please list any vaccinations that you are interested in receiving or learning more aboutQuestions for us?Submit
