Medical History

Please list all Current Medications (prescription or over-the-counter medications)

Vaccine History

Travel Details

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Additional Travel Information

PATIENT CONSENT

I acknowledge that I am the (1) above Traveler and an adult or (2) parent or legal guardian of the above minor Traveler and have requested a Travel Consultation “Travel Consult” for the Traveler from Nelson Remedys Rx, which is intended to provide general information and recommendations relevant to the above travel plans to the identified country(ies). I understand and agree that: The Travel Consult (i) may not provide an exhaustive pst of all risks associated with, or conditions to, the above travel plans; (ii) is not intended to be for diagnostic or treatment purposes; and (iii) may not be covered by insurance. Further, Nelson Remedys Rx may not be able to submit a claim to an insurer for the Travel Consult on behalf of the Traveler; and

I agree that the Pharmacist will give best effort in obtaining recommended Prescriptions for Travel Destination. However, the above Family Doctor may not accept recommendation for prescription products which would require the patient to go in to see Doctor for appointment for these prescriptions

I agree to full financial responsibipty for the Travel Consult and understand that payment for such service is due prior to the Travel Consult. I understand that Nelson Remedys Rx price for the Travel Consult does not include the cost for any (i) immunizations or prescriptions that I may request at Nelson Remedys Rx locations or (ii) any over-the counter travel-related products that I may purchase at Nelson Remedys Rx.

I have been told and explained the risks involved with any vaccinations that are needed according to the recommendations from the Pharmacist and consent to being given the recommended vaccines.