Travel Consult Information
The travel consultation by a pharmacist is $50 in addition to any copays for vaccines or travel medications needed for travel for each person. The consult includes recommendations, consulting your doctor for travel medications, and vaccinations with this fee. A member of our team will reach out to you to set up an appointment and will contact you within 72 business hours that your request was received. We require a minimum of 10 days before your trip to make your request for a travel appointment, and generally recommend contacting us 4-6 weeks prior to travel. Please submit a form for every person that will traveling on the trip. Thank you for choosing Bremo Pharmacy for your travel needs!
Name
*
First Name
Last Name
If 18 years or younger, name of parent/guardian
First Name
Last Name
Gender Assigned at Birth
*
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Care Physician
*
First Name
Last Name
Please upload insurance information
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Medical Conditions (check those that apply):
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Asthma
Cancer
Chronic Bronchitis
COPD
Congestive Heart Failure
Cirrhosis of the Liver
Diabetes (type 1 or type 2)
Heart Disease
HIV infection
Immune Deficiency
Organ Transplant
Splenectomy/ inactive spleen
Sickle Cell Disease
Tuberculosis (untreated)
None of these medical conditions
Current Medications:
During the the past 3 months, have you taken:
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Oral steroids
Chemotherapy
Radiation Therapy
None of the above
Please list any allergies:
If 18 years or younger, how much does the child weigh?
What countries are you traveling to?
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What cities will you be traveling to?
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Do you have any layovers?
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Yes
No
List all layovers and duration
What date are you leaving?
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-
Month
-
Day
Year
Date
What date are you returning?
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-
Month
-
Day
Year
Date
Are you traveling with a group or another person that is submitting for a travel consult, if so what is their name?
If any other members of your group also want a travel consult please submit another form for each person
What types of activities? (Safari, mission work, working with animals, etc.)
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Select all types of lodging you will use on your trip
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Hotel
Staying with friends/family
Camping
Hostel
Other
If "Other" please specify:
Do you plan to have contact with animals?
*
Please Select
Yes
No
Please provide more details
Are any of your destinations at elevation? (over 8,000 feet above sea level?)
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Please Select
Yes
No
Please provide locations and time at each location
Is there any other information we need to know to complete your travel consult?
By signing below, you agree to pay a $50 consultation fee for every person that is consulted for this trip in addition to any copays for vaccines or travel medications. You are entitled to all recommendations, prescriptions, and vaccinations with this fee recommended by the pharmacist.
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