Yellow Fever Travel History and Consent

Yellow Fever Vaccination Consultation

A member of our team will reach out to you within 48 business hours to set up an appointment. Since this vaccine requires special documentation by the pharmacist, an additional $25 fee will be required at the time of your appointment.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Sex

MaleFemale
Primary Care Physician
Have you ever received a yellow fever vaccine?

YesNo
Do you have a yellow fever card?

YesNo
Upload insurance card

Cancelof
Reason for Yellow Fever Vaccination
Travel Destination(s)
Dates of travel
Do you have any allergies?

YesNo
List allergies
Have you ever reacted to a yellow fever vaccine or do you have a first-degree family relative who has had a serious adverse reaction to the yellow fever vaccine?

YesNo
Do you have cancer or have you had cancer in the past?

YesNo
Are you having chemotherapy or radiotherapy (now or within the last year)?

YesNo
Are you living with HIV?

YesNo
Do you have any illness that might affect your immune system? (ie., leukaemias, lymphoma, cellular immune deficiencies, chronic lymphoproliferative conditions, or if you have ever received a stem cell transplant)

YesNo
Are you taking any medicines (now or within the last year) that affect your immune system? (ie., steroids, biological or non-biological immune modulating medicines, treatment following an organ transplant)

YesNo
Have you ever been told that you may have a problem with your thymus gland (includes myasthenia gravis or a thymoma)?

YesNo
Have you had an operation to remove your thymus gland (thymectomy) for any reason including during cardiac surgery?

YesNo
Have you had any recent vaccinations in the last 4 weeks?

YesNo
List any recent vaccines
For Women: Are your pregnant or plan to become pregnant?

YesNo
For Women: Are you breastfeeding?

YesNo
I acknowledge that I have read or have had read to me, the written information regarding the yellow fever vaccine being administered. I understand the benefits and risks of the yellow fever vaccine and have received a copy of the vaccine information sheet. I understand that I have the right to refuse the immunization and medication recommendations provided to me including waiving a full travel consult. I hereby release Bremo Pharmacy and its parent, subsidiary and affilates, and its officers, employees and agents, respectively, from any and all liability that might arise from this vaccination(s), for my decision to refuse any recommendations or any negative health outcomes that may occur due to this decision on behalf of me, my heirs and personal representatives.
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Date

MonthDayYear
Date
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Yellow Fever Vaccination Consultation