Travel Clinic Request Form

Please complete and return this form to travel coordinator. Once we receive and review this form we will contact you to schedule your travel consult visit. You can also download this form here to send through fax at 404-256-1759.

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General:

Patient name *

Date of Birth *

Phone *

Are you an established patient at Sandy Springs Pediatrics?

Are you an established patient at Sandys Springs Pediatrics? YES NO If NO, please complete New Patient Paperwork Form in addition to this form

Itinerary

City/Country #1

Mode of Travel

Arrival Date

Departure Date

Duration

City/Country #2

Mode of Travel

Arrival Date

Departure Date

Duration

City/Country #3

Mode of Travel

Arrival Date

Departure Date

Duration

City/Country #4

Mode of Travel

Arrival Date

Departure Date

Duration

City/Country #5

Mode of Travel

Arrival Date

Departure Date

Duration

City/Country #6

Mode of Travel

Arrival Date

Departure Date

Duration

Total Duration

1. What is the purpose of the patient's travel? (i.e. vacation, business, relocation, mission, study, etc.)

2. Describe any planned activities (i.e. hiking, caving, water activities, working with animals, etc.)

3. To what type of area will the patient travel to? (Urban/rural/urban and rural)

4. What type of accommodations will the patient be staying in? (i.e. hotel, resort, family home, hostel, etc.)

Medical History

1. Has the patient ever received the Yellow Fever Vaccine?

2. Has the patient ever had an adverse reaction to any injections?

If YES, please describe:

3. Check box if the patient has allergies to any of the following:

Sulfa
Eggs
Egg products
Chicken protein
Gelatin
None

4. Does the patient have a history of any anaphylactic reaction including medications, foods, or insect bites?

If YES, describe

5. Has the patient ever taken malaria prophylaxis?

If YES, what medication:

6. Check box if the patient has a history of any of the following:

Nightmares
Seizure/Epilepsy
Insomnia
Depression
Mental Health Disorder
Cancer
Immune Deficiency
G6PD Deficiency
Thymus Disorder
HIV/AIDS
Organ Transplant
Radiation Therapy
None of these

7. List ALL current medications, including prescription, non-prescription, supplements, oral contraceptive pills:

8. Has the patient had any blood product transfusions or injections in the last 12 months (i.e. blood transfusion, IVIG, VZIG, etc.)?

9. Is the patient currently or is there a chance that the patient could become pregnant during travel?

Please note that Travel Consults are not covered by insurance carrier. You will be require to self-pay for the visit and any vaccines if needed.

Office Use Only

Schedule with Dr. Robertson

Schedule with Any Provider

Notes:

Signature:

Date:

Scheduled: (circle one)

Date:

More Common Illnesses We Treat

Acne
Acute Gastroenteritis
Allergies
Asthma
Common Cold
Chicken Pox
Constipation
Covid-19
Cradle Cap
Croup
Diaper Rash
Diarrhea

Dosage Charts
Ear Infection
Fever
Flu
Hand, Foot and Mouth Disease
Head Injury
Head Lice
Hives
Impetigo
Ingrown Toenails
Microbiology for Parents
Mono

Nosebleeds
Pink Eye
Pinworms
Poison Ivy
Poisoning
Ringworm of the Scalp
Ringworm
Roseola
Strep Throat
Vomiting
Wheezing
Yeast Infection