1721 Main St Vancouver, British ColumbiaV5T 3B5, CAPhone: (604) 658-8881 Please enable JavaScript in your browser to complete this form.Traveler’s Name *Contact Phone *DOBComplete Travel ItineraryCities and Countries in order – and include any layoversDeparture DateDuration of TravelMajor Medical Conditions of Traveler?Has the traveler had the following vaccinations? *Hepatitus AHepatitus BMeningococcal (meningitis)TetanusVaricellaMMRYellow FeverTyphoidMedication Allergies *Has the patient been seen here previously?Who is the patient’s primary care provider?How did you hear about our travel clinic?Submit
