Form - General Visit

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Please fill out the form below prior to your visit,
OR print this form and bring to your visit.

Patient Demographics

Sex:

Information About Trip

Previous Travel Vaccinations (list year they were received)

Please list any adverse reactions to previous vaccinations:

Allergies

Please check yes or no and explain all “yes” answers:

Arthritis / Joint Pain
Asthma / Hayfever / Allergic Rhinitis
Bleeding Tendency / Blood Thinners
Depression / Anxiety / Panic Attacks
Diabetes
Eczema or Psoriasis
Heart Disease / Surgery / Pacemaker
High Blood Pressure
Immune Disorder
Impaired Vision or Hearing
Jaundice or Hepatitis
Muscle or Bone Disease
Nervous System Disorder
Renal (Kidney) Disease
Respiratory (Lung) Disease
Seizures / Convulsions / Fainting
Sickle Cell Anemia
Stomach Ulcers / Heartburn / Reflux
Surgery or Hospitalization in past 3 years
Thymus Gland Disorder
Thyroid Disease or Goiter
Tuberculosis
Have you been treated for illness or injury in the past 2 years?

Thank you for choosing Great Lakes Physician Services for your travel immunization needs.  At your visit, our experienced providers will consult with you regarding the vaccinations that you are requesting.  If you are traveling abroad, our providers will discuss with you all the information you need to help you stay healthy during you trip.

Please be aware that we DO NOT participate with any insurance companies.  Once you meet with our provider and determine which immunizations you will be receiving, you will be expected to pay for those immunizations along with an office visit fee.  If you need to return to complete a series of shots (i.e. Hepatitis B), you will only be charged one office visit fee for the entire series. For family members or small groups that come in together ,there will only be one office visit fee assessed (1-3 people fee is $50, 4-6 people fee is $60, 6 and over will start at $75 but will be determined by size of group.  We accept Visa, Master Card, or Cash as means of payment.  At the time of payment, you will be provided with itemized receipts that contain all of the information that you will need for insurance submission purposes.  We cannot guarantee that your insurance provider will reimburse any of your costs for these services.  The amount reimbursed to you, if any, is dependent upon you’re the terms of your insurance plan.

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