CALL US
780-476-4747
E-MAIL
info@apollopharmacy.ca
LOCATION
6570 170 Ave NW

Travel Form

Name

Date of Birth

Information

Smoker?

Allergies

Egg AllergyLatex AllergyDrug Allergy

Please indicate if you have any of the following conditions

Heart DiseaseCancer or recent Chemotherapy (last 3 months)DiabetesImmunocompromisedOrgan/marrow transplantPregnancy/Trying to conceiveReflux/HeartburnSpleen removedSeizure disorder

When will you be leaving?

Countries to Be Visited

Cities and Areas to be Visited

Please indicate below the countries, areas and cities visited, and the duration of your stay in urban and/or rural areas.

For Country 1, what type of locations will you be staying at?

For Country 2, what type of locations will you be staying at?

For Country 3, what type of locations will you be staying at?

For Country 4, what type of locations will you be staying at?

Purpose of Visit

Pleasure /holiday Visiting family / friendsBusinessEducation/study/summer campVolunteer/relief workReligious visitAdoption

Please specify below any other reasons

Where will you be staying?

1 st class hotel/ resort or cruise shipBudget hotels and/or hostelsInns/B&BsFamily/friendsCampingCompany lodgeAirBnB / House share

Possible Activities

High altitude/climbingUnderwater diving/snorkelingJogging/running/bicyclingRafting/water sportsWilderness/extreme sportHealthcare activitiesVolunteer humanitarianSafariActivities involving contact with animals (Veterinary)

Immunization History
Fill to the best of your ability or check box only

Vaccine

Cholera (Dukoral)

Date of Last Dose

Vaccine

Polio (IPV)

Date of Last Dose

Hep A - Dose 1

Rabies

Hep A - Dose 2

Td (Diphtheria /Tetanus)

Hep A & B combo (Twinrix) - Dose 1

Tdp (Diphtheria/ Tetanus/ Polio)

Hep A & B combo (Twinrix) - Dose 2

Tda

Hep A & B combo (Twinrix req. 3 doses) - Dose 3

Tick Borne Encephalitis

Hepatitis A & Typhoid combo

Typhoid Fever

Hep B (Hepatitis B)

Yellow Fever

HPV (Gardasil/Cervarix)

ZOS (Zoster) (Shingles)

JE (Japanese Encephalitis)

Pneumococcal

Mantoux Test (TB Skin Test)

Meningitis

MMR (Measles Mumps Rubella)

Do you need Influenza or Pneumococcal vaccinations?

Do you need assistance with walking aid selection or Compression stockings?

Note:
There are fees associated with the services not covered by Alberta Health described on this form (ex. vaccines, pharmacogenomics testing and travel education). Some of these may be covered through 3rd party insurance. Please contact the store for more information.
Travel Note:
Vaccines are generally well tolerated. Some patients may experience some soreness, redness and swelling at the injection site. As with any vaccine, other side effects including an allergic reaction or anaphylactic response could occur.