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
Hidden
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.

Additional Services
Check-in Online