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.
** Insurance Billing: Majority of medical insurance plans will not cover the cost of adult immunizations. Because of this reason, our clinic is not a member of any insurance network and is unable to submit insurance billing for you.
I would like to schedule an appointment for: *

Travel Medicine Consult & Review Yellow Fever Vaccine - Requires Consult and Review Malaria Medication- Requires Consult and Review Booster Shot Follow Up Other option
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 *
Primary Phone Number *

- Area Code Phone Number
Type of phone number above?

Mobile Cellphone Home Office
Alternate Phone Number

- Area Code Phone Number
Number of Patients Requesting Appointments *
Additional Name for Appointment

First Name Last Name
Type of Travel *

Vacation Business Cruise Adventure Travel Study Abroad Foreign Relocation Missionary Other Other option
Online schedule request received after hours or weekends will be processed the next business day.

Schedule at least three (3) or more business days from today.

AVAILABLE APPOINTMENT HOURS:

MONDAY: 0830 AM to 1230 PM and 0230 PM to 0430 PM

TUESDAY: 0830 AM to 1230 PM

WEDNESDAY: 0830 AM to 1230 PM and 0230 PM to 0430 PM

THURSDAY: 0830 AM to 1230 PM

FRIDAY: 0830 AM to 1230 PM

PLEASE NOTE: Clinic is closed on all USA Federal Holidays
Primary Appointment DATE and TIME Request *

- Month - Day Year
at
: Hour Minutes
Secondary Appointment Date and Time Request *

- Month - Day Year
at
: Hour Minutes
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 Other option
Copyright MMXVII. 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.
Should be Empty:

Healthy Traveler Online Appointment Request