St. Alphonsus Regional Medical Center
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Travelers Questionnaire

Our Nurse Travel Coordinator will review the information. Depending on your travel destination and information provided, our Travel Coordinator will contact you with the appropriate information and or schedule an appointment.

Payment for immunizations and other services is expected at the time of service. Saint Alphonsus will bill your insurance and refund to you any reimbursement from your insurance.

* Indicates required information
First Name * 
Last Name * 
Date of Birth *  (mm/dd/yyyy)
Phone Number * 
Best time to contact you at this number * 
Secondary Phone Number 
Best time to contact you at this number 
What is your travel destination (s) in order of country to be visited? * 
What are your travel dates (departure through return)? * 
What are you going to do on your trip (i.e. go on a safari, do charity work, etc.)? * 
Have you previously traveled to this country? * 
If you have previously traveled to this country, when? 
What previous immunizations have you had? * 
Do you currently have any medical problems (i.e. high blood pressure, diabetes)? * 
Do you have a primary care physician? (please list) * 
Do you currently possess a physician's order or prescription for your travel immunizations? * 
Are you currently taking any prescription medications? * 
If yes, please list your prescription medications. 
Do you have any allergies? * 
If yes, please list your allergies. 
Do you have an official immunization record? If yes, please bring with you at the time of your appointment. If no, can you get a copy from your medical record at your physician's office? * 
Authentication * 

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 2014  

Saint Alphonsus Regional Medical Center  |  1055 N. Curtis Road  |  Boise, Idaho 83706  |  208-367-2121

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