Intravene Home


Division of Medical Associates of Central Virginia, Inc.
434-947-3900
 info@intravene.net

    
Travel Clinic Information Sheet
Patient Name:
Address:
City:
State:    Zip: 
Home Phone:
Work Phone:
Other phone:
E-mail:
Date of Birth:

Where are you going? You can choose more than one.
 
Brazil  China  Dominican Republic  Egypt  Hong Kong
India  Japan  Mexico  Nepal  Philippines  Romania
Russia  Saudi Arabia  Thailand  Turkey  Zimbabwe

Other:
 
Specify/Describe the area you will be traveling:

 
Departure date:
Return date:

Do you have allergies to any of the following?
 
Eggs  Yeast  Neomycin  Thimerosal  

Other:
 
Any current illnesses or past medical history? If so, please specify:
 
Have you had any vaccines? If so, please specify type and date: