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
OUR CLINIC IS OPEN BY APPOINTMENT ONLY

• PROPER FACE MASK IS REQUIRED PRIOR TO ENTRY
• TEMPORAL TEMPERATURE CHECK WILL BE TAKEN PRIOR TO SERVICE
• 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.
DUE TO INCREASE DEMAND FOR AN APPOINTMENT,
SECOND APPOINTMENT DATE SHOULD BE 1-2 WEEKS APART.
Appointment requests after clinic hours, on weekends, or on holidays
will be processed when the clinic opens.
I would like to schedule an appointment for: *

Travel Medicine Consult, Review Travel Plans & Vaccines Yellow Fever Vaccine - Requires Consult and Review Malaria Medication- Requires Consult and Review Meningitis Vaccine Typhoid Vaccine Tdap (Tetanus, Diphtheria & Whooping Cough) Return for Booster Shot(s) Seasonal Flu Shot - Regular Dose Seasonal Flu Shot - High Dose for 65+ years old
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 & Text Phone Number *

Area Code Phone Number
Secondary Contact Phone Number

Area Code Phone Number
Type of Alternate phone number above?

Mobile Cellphone Home Office
Enter FIRST date you would like to schedule on a Tuesday, Wednesday, or Thursday: *

Month Day Year
Date
Your FIRST appointment date above, choose one of the following: *

Morning Appointment Afternoon Appointment
Enter SECOND alternate date you would like to schedule on a Tuesday, Wednesday, or Thursday:

Month Day Year
Date
Your SECOND appointment date above, choose one of the following:? *

Morning Appointment Afternoon Appointment
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
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 Centers for Disease Control Website Google Search Engine Yahoo Search Engine Bing Search Engine Facebook Twitter Pasadena Public Health Department
Copyright MMXXII. 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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