To have a representative contact you about your foreign travel medical needs, please complete the fields below.

All fields are required unless indicated as optional.

"*" indicates required fields

Your Name:*
Sex:*
MM slash DD slash YYYY
This field is hidden when viewing the form
MM slash DD slash YYYY
Please list all cities/countries.
What is the purpose of your trip?*

Are you staying mostly in cities/tourist destinations?*
Are you going to spend time in a rural area?*
Are you going to spend time above 5000 ft?*
Are you going to work in the foreign country?*
Are you currently being treated for any medical problems?*
Have you had a significant medical problem in the past?*
Could you be pregnant?*
Are you allergic to eggs or chicken products?*
Have you had any hypersensitivity or reaction to vaccinations?*
Have you had Guillain-Barre Syndrome?*
Have you had all of your childhood vaccinations?*
Have you had tetanus/diphtheria vaccination in the last 10 years?*
Have you had measles vaccination (2 shots)?*
Have you had polio vaccination as an adult?*
Have you had hepatitis A vaccination (2 shots)?*
Have you had hepatitis B vaccination (3 shots)?*
Have you had meningitis vaccination in the past 3 years?*
Have you had typhoid vaccination in the past 2 years (if injected), or in the past 5 years (if oral)?*
Have you had yellow fever vaccination in the past 10 years?*
Have you had Japanese encephalitis vaccination in the past 2 years?*
Do you have any current or previous significant medical conditions?*
Are you currently taking any medications (prescription or over-the-counter)?*
Please include all prescription and over-the-counter medications being taken currently.
Do you have any allergies?*
This field is for validation purposes and should be left unchanged.

Doctors Care has board certified physicians with expertise in travel medicine who are specially certified to administer specific foreign illness vaccines. Our services include pre and post consultations, immunizations and other preventive health recommendations and services customized to your needs.

Find out more about our travel medicine services