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FAQ
Who We Are
Our Staff
Accreditation
Compounding
Compounding Solutions
RX Refills
Consultation Services
Compounded Hormone Therapy
Foreign Travel & Immunizations
Pain Management
Veterinary Needs
Hospice Needs
CBD
Contact Us
FAQ
Foreign Travel Questionnaire
Foreign Travel Questionnaire
Travel Immunization Services
FIRST NAME:
(Required)
LAST NAME:
(Required)
DATE OF BIRTH:
(Required)
Pronouns:
She/her
He/him
They/them
ADDRESS:
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
ADDITIONAL FAMILY MEMBERS/PERSONS ON TRIP
Add
Remove
You may list additional members accompanying your trip. Please note a form must be filled out for each individual person
TELEPHONE:
(Required)
EMAIL:
BEST TIME OF DAY TO BE REACHED:
Morning (8:30am-11:30am)
Afternoon (12pm-4:30p)
No preference
Please note it can take up to 24 to 48 hours to process requests
Primary Care Provider:
Name of Office/Clinic
Office/Clinic Telephone:
HAVE YOU RECIEVED IMMUNIZATIONS OUTSIDE THE STATE OF MICHIGAN?
Yes
No
Not Sure
COUNTRIES AND CITIES IN ORDER OF VISIT:
Add
Remove
For Cruise trips you may list the name of the cruise line and name of voyage
DATES OF TRAVEL:
TRIP PURPOSE:
Vacation
Education/Research
Missionary/Volunteer/Humanitarian Relief
Visiting Family/Friends
Working in Medical Setting
Work (urban, office-based, or confrence)
Vaccines required for Employment
Other
ACCOMODATIONS:
Resort/Large Hotel
Airbnb/Hostel
Cruise Ship
Primitive Camping
Safari
Staying with Family/Locals
PLANNED ACTIVITIES: (i.e. mountain climbing, scuba diving, etc)
ALLERGIES:
Please list ALL allergies (i.e, medications, food, latex, etc)
IMMUNE SYSTEM:
(Required)
Immune suppresive medications
Spleen removal
Thymus disease or thymectomy
HIV/AIDS
Transplant
None of the Above
CANCER/BLOOD DISORDERS:
(Required)
Coagulation (clotting disorder)
History of cancer or blood disorder
Other
None of the Above
OB/GYN
(Required)
Pregnant/Possibly Pregnant
Planning Pregnancy
Breastfeeding
Not Applicable/ None of the above
GI:
(Required)
Crohn's Disease or ulcerative colitis
IBS
GERD
Chronic Hepatitis/ Cirrhosis/Liver Failure
None of the Above
YOU MAY ADD ADDITIONAL MEDICAL CONCERNS HERE:
