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Traveler Information Form

What is this form used for?

This form collects important medical history and travel information which is used by IMC’s physicians to determine which vaccines and medications are appropriate for you. We must receive a completed form before we can confirm your appointment. It will shorten your time at our facility.

Online Form Option

What information do I need before starting?

  • Destinations (city and country), departure date, and length of stay
  • Prescription and non-prescription medications
  • Chronic medical conditions
  • Immunization history
  • Allergies
  • If we are billing your company: your supervisor’s name, and cost center number

If you want to use the online form, click the link below.

Start a New Form

Print and Fax Option

If you are more comfortable filling out a paper-based form, you can download and print our Adobe PDF version here. After you complete the form, fax it to the number printed on the form.