Our offices are now open by scheduled appointment only. COVID-19 precautions are in place following Public Health Guidelines.

Quinte Travel Health Clinic

TRAVEL ITINERARY & IMMUNIZATION HISTORY

We adhere to the Personal Information Protection Act to protect your privacy

Accessibility Services are available at our location. If required, please contact our office in advance of your appointment for directions to the elevator / office access or CLICK HERE for full details.

PLEASE COMPLETE ONE QUESTIONNAIRE FOR EACH PERSON ATTENDING

Would you like to book your appointment in Kingston or Belleville? Kingston Belleville

First Name:

Last Name:

DOB (d/m/y):

Home Phone Number:

Address:

City:

Postal Code:

Email:

Family Physician:

Phone Number:

Emergency Contact:

Phone Number:

Relationship:

Departure Date (d/m/y):

Duration of Trip: days weeks months

	Countries to be Visited	Cities & Areas to be Visited	Duration in Urban areas	Duration in Rural areas
1
2
3
4

Purpose of trip
Pleasure/holiday Visiting family/ friends Business (specify)	Education/study/summer camp Volunteer/relief work Religious visit	Adoption Other:
Where will you be staying?
1 st class hotel/ resort or cruise ship Budget hotels and/or hostels Inns/B&Bs	Family/friends Camping Company lodge	Other:
Possible activities
High altitude/climbing Underwater diving/snorkeling Jogging/running/bicycling Rafting/water sports	Wilderness/extreme sport Healthcare activities Volunteer humanitarian Safari	Activities involving contact with animals (Veterinary) Other: Other:

IMMUNIZATION HISTORY
Vaccine	Date of Last Dose	Vaccine	Date of Last Dose
Cholera (Dukoral)		Polio (Imovax-Polio)
Hep A - Dose 1 (Avaxim; Havrix)		Rabies (Imovax; Rabavert)
Hep A - Dose 2 (Avaxim; Havrix)		Td (Tetanus/Diphtheria)
Hep A & B combo - Dose 1 (Twinrix)		Tdp (Tetanus/Diphtheria/Polio)
Hep A & B combo - Dose 2 (Twinrix)		Tdap (Adacel; Boostrix)
Hep A & B combo - Dose 3 (Twinrix)		Tick Borne Encephalitis
Hepatitis A & Typhoid combo (Vivaxim)		Typhoid Fever (Vivotif; Typhim Vi; Typherix)
Hepatitis B (Engerix B; Recombivax HB)		Yellow Fever (YF-Vax)
HPV (Gardasil/Cervarix)		Shingles (Zostavax; Shingrix)
Influenza (Fluzone)		Covid Booster:
Japanese Encephalitis (Ixiaro)		Other:
Mantoux Test/TB Skin Test(Tubersol)
Meningitis (Menactra; Menjugate)
Measles Mumps Rubella (MMR II; Priorix)
Pneumococcal (Prevnar 13; Pneumo 23)

Are you currently taking any medications? Please specify:

Have you ever had an adverse reaction to a vaccine? Please specify:

Where did you hear of us?

I declare that all the information provided on this form is accurate to the best of my knowledge and I understand that any false information could be detrimental to my health.

I understand there are clinic fees associated with appointments (Clinic fees are listed on our webpage.).*

Date: 21/12/2024 (d/m/y)

Note: Most vaccines are generally well tolerated; however, you may experience some soreness, redness and swelling at the injection site. Other adverse reactions may include headaches, fever, fatigue, and muscle pa in. As with any vaccine, an allergic reaction or anaphylactic response could occur.

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Terms and Conditions