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First Name *
Last Name *
Are You 18 Years of Age or Older?
Are You Over The Age of 60?
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Best Contact Number *
Email Address *
Primary Care Provider
Pharmacy of Choice
How Did You Hear About Trip Rx? *
Please select an option Church/Mission Group (please specify church/mission group in “other” field below) Community Center (please specify community center in “other” field below) Community Event (please specify community event in “other” field below) Email from TPCA Facebook Health Department or Wellness Center (please specify name in "other" field) Healthcare Provider (please list your healthcare provider's name in the "other" field) Internet Search Radio Returning Patient Study Abroad Program (please specify study abroad program in “other” field below) Tallahassee Democrat Tallahassee Magazine TPCA Website TV Commercial- ABC 27 TV Commercial-NBC 40 Word of Mouth Other (please specify in the "other" field below)
Have you ever had an allergic reaction to eggs, mercury (thimerosal), bee stings, formaldehyde, or sunlight?*
Please enter your 1) Destination(s), 2) Method of Transportation, and 3) Length of Stay (for all destinations)
TRAVEL ITINERARY INFORMATION
Many vaccinations and prophylactic treatments are dependent upon the actual regions and cities that you may be visiting. In order to help you best prepare for your travels as well as spare you any unnecessary costs, please give as much detail as you are able regarding your plans.
Are there any medications to which you have had an allergic reaction?
Date of Return *
Date of Initial Departure *
Organization or Group Associated with Travel
Number of Persons Traveling With You: (please enter a number)
What will be the primary purpose of this trip?
Please describe in detail all that is known about your lodging and dining arrangements for this trip:*
Travel vaccines are a very important tool in the prevention of viruses, illness and disease, specifically those associated with travel outside of the United States and Canada.
In addition to routine immunizations such as Tetanus, Influenza (Flu) and Pneumonia, the CDC and World Health Organization (WHO) track common illnesses and outbreaks as they occur across the globe.
The TPCA Travel Medicine and Vaccine clinic uses the latest recommendations from the CDC and the WHO in regards to providing you with information about vaccines and other forms of prevention.
In providing vaccines, we have learned that most insurance companies
do not cover charges related to travel. This being said, we request that each patient be personally responsible for payment of charges when services are rendered. We will not file charges associated with travel to any insurance company, nor will we accept insurance assignment for these services.
By signing below, you understand and accept our above stated notice.
Type Your Name to Sign *
PLEASE BRING ALL PREVIOUS IMMUNIZATION RECORDS (OR LEGIBLE COPIES) WITH YOU TO YOUR INITIAL VISIT.
Thank you again for choosing Tallahassee Primary Care Associates. We look forward to helping you plan for safe and joyous travels!