Online Appointment Request

HEALTHY TRAVELER ONLINE APPOINTMENT REQUEST

To request an appointment, please complete and submit this form.

If you need further assistance, please call us at 626-584-1200.

1250 East Green Street • Pasadena • CA • 91106

www.healthytraveler.com
** Information About Insurance Billing**

Travel Immunizations are generally NOT a covered benefit of your insurance if you have:

• Medical Insurance Paid by your Employer

• Medicare including Part D, and Secondary Payer

• Medi-Cal or Medicaid

Because this is a non-covered benefit, we are unable to provide medical billing.
I would like to schedule an appointment for: *

Travel Medicine Consult, Review & Vaccines Yellow Fever Vaccine - Requires Consult and Review Malaria Medication- Requires Consult and Review Meningitis Vaccine Only-no other vaccines Typhoid Vaccine Only-no other vaccines Return for Booster Shot(s)
Are you? *

New Patient Returning Patient- last visit less than 12 months ago. Returning Patient- last visit more than 12 months ago. Minor under 18 Age 64+
Full Name *

First Name Last Name
E-mail *
Your Cellular Mobile Phone Number *

Area Code Phone Number
Secondary Contact Phone Number

Area Code Phone Number
Type of Alternate phone number above?

Mobile Cellphone Home Office
Number of Patients Requesting Appointments *
Additional Name for Appointment

First Name Last Name
Additional Name for Appointment

First Name Last Name
Additional Name for Appointment

First Name Last Name
Type of Travel *

Vacation Business Cruise Adventure Travel Study Abroad Foreign Relocation Missionary Other
Please allow at least three (3) business days from today to request an appointment datea and time. Please review our available appointment hours above.
Primary Appointment DATE and TIME Request *

Month Day Year Hour Minutes AM/PM Option
Secondary Appointment Date and Time Request *

Month Day Year Hour Minutes AM/PM Option
Departure Date of Travel *

Month Day Year
Date
Countries of Travel *
Please list by Country Name or City or Region
Additional Message to Clinic:
List of vaccines needed., medical concerns..etc.
Referral to Healthy Traveler Clinic by:

Returning Patient Referral from Physician Referral from Friends/Family Read Article about Healthy Traveler Centers for Disease Control Website Google Search Engine Yahoo Search Engine Bing Search Engine Facebook Twitter Advertising
Copyright MMXVIII. Healthy Traveler® is a registered trademark with the United States Patent and Trademark Office and Canadian Office of Intellectual Properties. No whole or partial reproduction of this website including printed or electronic is allowed without written permission from Healthy Traveler. All Rights Reserved.
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