Travel Consultation

THE PRE-APPOINTMENT FORM MUST BE COMPLETED BEFORE YOUR APPOINTMENT

PATIENT CHECK-IN FORM

Name*

Title

First

Last

Date of Birth*

day

month

year

Address*

Street Address City State / Province / Region Postal / Zip Code Country

Primary Health Care Provider*

Email Address*

Cell Phone*

Assigned Sex at birth*

Male

Female

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.

Signature Date*

Signature (Draw)*

PRE-TRAVEL FLOW SHEET

Age*

Initials of your Name*

Departure Date*

How did you hear about our clinic?*

List the countries you plan to visit, in order

Country

Duration

Specific Destination

MEDICATIONS

Are you taking any medication?*

Yes

List the name of the medication(s)

Are you taking pills for epilepsy, or blood thinners?*

Yes

If so, please list the medication(s)

MEDICAL HISTORY

Do you have any medical problems?*

Yes

If so, please list them

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.

Submit your proof of insurance coverage details (if applicable).

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.**

Travel Consultation – Cornwall Travel Health | Long Sault Region

Our service

Appointments may be conducted outside of regular Long Sault Pharmacy store hours. Please wait at the front door at your designated appointment time.

Book your travel consultation

Cornwall Area Travel Clinic

Resources

Our Services

Our Pharmacy Hours