PATIENT CHECK-IN FORM

Acknowledgment of Medical Directive:

I understand that I will fill out this questionnaire as completely and accurately as possible as it is used to make travel

health recommendations for my particular trip.

I understand and consent that this medical information may be shared with the Merivale Medicale Center and Dr. Cherinet Mohammed Seid for the sole purpose of providing travel health medical services for your trip.

I understand and consent that vaccines may be prescribed and administered by a registered pharmacist David Mancini (license #616898) under a medical directive provided by Dr. Cherinet Mohammed Seid of the Merivale Medical Centre and a copy of the medical directive can be provided to you upon request.

I understand that health card information provided may be used to access online medication records.

I understand that I have a choice where medications and vaccines prescribed through this service, may be sent to a pharmacy of my choosing.

PRE-TRAVEL FLOW SHEET

MEDICATIONS

MEDICAL HISTORY

HEPATITIS-A IMMUNITY

IMMUNE DEFICIENCY

ALLERGIES/INTOLERANCES

To the best of your knowledge, are you allergic to:

ANTI-MALARIALS

As far as you know, do have problems with:

Have you ever had:

WOMEN ONLY

YOUR IMMUNIZATION HISTORY

Have you had the:

Have you ever had the following immunization?

INSURANCE COVERAGE

The consultation fee is not covered by provincial health care. Some medications and vaccines are covered by both provincial and private drug benefit plans. We advise you to check with your benefit company for more details on coverage.

Thank you for completing the pre-appointment forms. Once you click submit form, It will be forwarded to the pharmacist at your chosen location. Please note that the form is only valid with an appointment booking. Once submitted you may proceed with scheduling a travel consultation.

**PLEASE DO NOT CLOSE THE PAGE UNTIL YOU SEE A CONFIRMATION MESSAGE.**