Online Appointment Request

Welcome!

Appointment Request Online

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
OUR CLINIC IS OPEN BY APPOINTMENT ONLY

MONDAY, TUESDAY, WEDNESDAY, THURSDAY AND FRIDAY
CLINIC IS CLOSED USA FEDERAL HOLIDAYS

• WE RECOMMEND USE OF A FACE MASK
• ENTRY FOR PATIENTS ONLY. No guests or companions are allowed with you.

If you have any concerns, please call or text:

626-584-1200
or send us a text 626-344-7544

All calls and texts are monitored 24/7 and we respond on a timely basis.
** Information About Insurance Billing**

VACCINES FOR TRAVEL MAY NOT BE A COVERED BENEFIT IF YOU ARE:
• Medical Insurance Paid by your Employer
• Medicare including Part D, and Secondary Payer
• Medi-Cal or Medicaid
At the end of your visit, your statement will include billing codes for submission.
We are not a member of any insurance network and cannot bill directly.
I would like to schedule an appointment for:*

Travel Medicine Consult, Review Travel Plans & VaccinesYellow Fever Vaccine - Requires Consult and ReviewMalaria Medication- Requires Consult and ReviewMeningitis Vaccine Only- No Travel ConsultationTyphoid Vaccine Only- No Travel ConsultationTdap Only (Tetanus, Diphtheria & Whooping Cough)-No Travel ConsultationReturn for Booster Shot(s)Seasonal Flu Shot Only - Regular DoseSeasonal Flu Shot Only - High Dose for 65+ years oldOther
Are you?*

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

First NameLast Name
E-mail*
Your Cellular Mobile & Text Phone Number*

Area CodePhone Number
Secondary Contact Phone Number

Area CodePhone Number
Type of Alternate phone number above?

Mobile CellphoneHomeOffice
Enter FIRST date you would like to schedule:*

MonthDayYear
Date
Your FIRST appointment date above, choose one of the following:*

Morning Appointments, Monday to Thursday, 0900 AM to 1200 PMAfternoon Appointments, Monday to Thursday, 0100 PM to 0300 PMFriday Morning Appointment, 0900 AM to 1200 PM.
Enter SECOND alternate date you would like to schedule:

MonthDayYear
Date
Your SECOND appointment date above, choose one of the following:?*

Morning Appointments, Monday to Thursday, 0900 AM to 1200 PMAfternoon Appointments, Monday to Thursday, 0100 PM to 0300 PMFriday Morning Appointment, 0900 AM to 1200 PM.
Number of Patients Requesting Appointments*
Additional Name for Appointment

First NameLast Name
Additional Name for Appointment

First NameLast Name
Additional Name for Appointment

First NameLast Name
Type of Travel*

VacationBusinessCruiseAdventure TravelStudy AbroadForeign RelocationMissionaryOtherOther
Departure Date of Travel*

MonthDayYear
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 PatientReferral from PhysicianReferral from Friends/FamilyCenters for Disease Control WebsiteGoogle Search EngineYahoo Search EngineBing Search EngineFacebookTwitterPasadena Public Health DepartmentOther
Copyright MMXXIV. 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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