Vaccine and International Travel Health Questionnaire
Please Print Clearly
Name:________________________________________________________
Last Name
First Name
Age:____ DOB:____________ Sex: M F T
MI
MM/DD/YYYY
Home Address:___________________________________________________ ________________________ _______ _________
Street Address
Phone:___________________________
Home or Cell
City
State
Zip
________________________ Email:__________________________________________
Work
Occupation:____________________________________________Employer:___________________________________________
SSN:__________________________________________
Primary Care:__________________________________________
Emergency Contact:________________________________________ ________________________ ________________________
(required)
Name
Relationship
Phone Number
Insurance name and policy number:___________________________________________ Subscriber:_____________________
Pharmacy Name/Address:_____________________________ Secondary insurance number:______________________________
Travel Information
Please list the countries you are traveling to, in the order you will visit them:
Date of Departure
Destination (City, Country)
Date of Return or Transfer
Length of Stay
Please mark all that apply to your travel plans:
Purpose:
___Leisure
___Adoption
___Study Abroad
___Business
___Missionary
___Other
Accommodations:
Activities:
___Resort
___Hotel
___Cruise Ship
___Rural Travel
___Staying with Family/Relatives
___Sightseeing ___Climbing/Hiking
___Camping
___Safari
___Business Meetings
Who arranged your Trip: _________________________________________________
___________________________
Name
Phone
Immunization History:
1) What was the date of your last tetanus/diphtheria (Td/Tdap) injection?
_______/__________/__________
2) Have you had chickenpox, or received two (2) doses of the varicella vaccine?
Yes
No
Unknown
3) Have you ever had a reaction to a vaccine that required medical treatment (a doctor’s office visit or emergency care)?
If yes, please explain the specific type of reaction:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
4) Please list any vaccines you have received in the past 30 days:
___________________________________________________________________________________________________________
5) Have you ever travelled outside of the U.S. and received travel vaccinations for that trip? If so, when and where?
___________________________________________________________________________________________________________
Medical History:
Do you have any medical problems? ____________________________________________________________________________
Please list any past surgeries: ________________________________________________________________________________
Are you allergic to ANY medications, latex, vaccinations or vaccine component, thimerosol, protamine sulfate, or mercury (a
preservative)?
_______________________________________________________________________________________________
Are you currently taking antibiotics?
Are you allergic to eggs, yeast, or any other foods?
Yes
Are you currently experiencing any respiratory infections or
other acute illness or infections?
Do you have any immune system problems, such as
cancer, HIV, or AIDS?
Have you had your thymus gland removed or a history of
problems with your thymus, such as myasthenia gravis,
DiGeorge Syndrome, or thymoma?
No
Yes
No
Yes
No
Yes
No
Do you take any cortisone, prednisone, steroids,
chemotherapy, or other biologic (e.g., Humira,
Remicade, etc.)?
Have you ever fainted from an injection or from
having your blood drawn?
Do you have ANY other health issues for which you
see a health professional? Please describe:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Are you currently taking any medications
(including oral contraceptive) or planning any new
medications during your trip? Please list:
Do you smoke?
Yes
No
Questions for Women: Please circle your response
Do you use a contraceptive or birth control (e.g., condoms, pills, surgical sterility)? YES
Are you pregnant? YES NO
Do you plan to become pregnant in the next three (3) months?
YES NO
Are you currently nursing? YES NO
NO
How did you hear about us?
___Established Client
___School/College
___Physician
___Employer
___Friend/Relative
___RVIDS Website
___Travel Agent
___Other ________________________________________
___CDC Website
By signing, I am stating that the above information is true and accurate to the best of my knowledge. Depending on your insurance, River
Valley Infectious Disease Specialists may file a claim for services. Some vaccines may not be covered by your insurance plan. Please call
your insurance in advance to verify your coverage. RVIDS is not responsible for knowing your plan’s coverage of vaccinations. Payment for
vaccines not covered by your plan is due at the time of service by cash, check, or credit card.
Traveler/Patient Signature ___________________________________________________________________
(under 18 years of age must have parent/guardian signature)
Date_________________________
RIVER VALLEY INFECTIOUS DISEASE SPECIALISTS
Patient Financial Responsibility Form
Name: _____________________________________ Date of Birth: _____________
Patient Financial Responsibilities





The patient (or patient’s guardian, if a minor) is ultimately responsible for payment for treatment and care.
We are pleased to assist you by billing our contract insurers. However, the patient is required to provide us with
the most current and updated information about their insurance, and will be responsible for any charges
incurred if the information provided is not correct or updated.
Patients are responsible for the payment of copays, coinsurance, deductibles, and all other procedures or
treatment not covered by their insurance plan. Payment is due at the time of service. For your convenience we
accept cash, check and most major credit cards.
Patients may incur, and are responsible for payment of, additional charges at the discretion of River Valley
Infectious Disease Specialists. These charges include, but are not limited to:
 Charge for returned checks.
 Charge for copying and distribution of patient medical records.
 Charge for extensive forms completion.
 Any costs associated with collection of patient balances.
If a patient does not cancel his/her appointment by 10 a.m. one (1) working day in advance, the patient will
be considered a “no show” and may be subject to a charge of $25. Repeated appointment cancellations or “no
shows” may be cause for dismissal from the practice. Please initial here. __________
Patient Authorizations

By my signature below, I hereby authorize assignment of financial benefits directly to River Valley Infectious
Disease Specialists under standard third party contracts. I understand that I am financially responsible for
charges not covered by this assignment.
 By my signature below, I authorize River Valley Infectious Disease Specialists personnel to communicate with me
regarding my financial information by mail, voice mail, message and/or e-mail according to the information I
have provided during my patient registration.
 I authorize any holder of medical or other information about me to release to the Health Care Financing
Administration and its agents of other insurances any information needed to determine these benefits or
benefits for related services.
I HAVE READ, UNDERSTAND AND AGREE TO THE PROVISIONS OF THIS PATIENT FINANCIAL RESPONSIBILITY FORM:
________________________________________
Signature of Patient or Guardian
_____________________
Date
Waiver of Patient Authorizations
I prefer to pay at the time of service and/or to be fully responsible for payment of charges.
________________________________________
Signature of Patient or Guardian
_____________________
Date
River Valley Infectious Disease Specialists
A)
HIPAA Notice of Privacy Policies – Acknowledgement of Receipt
I have received a copy of the HIPAA Notice of Privacy Policies for River Valley Infectious Disease Specialists that
explains my rights and documents policies and procedures that will safeguard my private health information.
Signature _____________________________________________Date________________
B)
Authorization of Payment
I authorize payment of medical benefits by my insurance company for all covered services provided by River Valley
Infectious Disease Specialists.
Signature _____________________________________________Date _____________
C)
Authorization to Release Information
I authorize the release of any medical information or other information necessary to River Valley Infectious Disease
Specialists process my insurance claim.
Signature _____________________________________________Date ______________
FOR MEDICARE PATIENTS ONLY (Medicare does not cover Travel Medicine visits)
D)
Medicare Authorization
Patient (Beneficiary) Name__________________________________ Policy #_____________
I request that payment of authorized Medicare benefits be made to me or on my behalf to River Valley Infectious Disease
Specialists for any services furnished me. I authorize any holder of medical information about me to release to the
Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits of
the benefits payable for related services.
Patient (Beneficiary) Signature________________________________Date________________
E)
Medigap Authorization (Medicare secondary insurance if applicable)
Patient (Beneficiary) Name__________________________________
Insurance Company______________________________________Policy#________________
I request that payment of authorized Medigap benefits be made to me or on my behalf to River Valley Infectious Disease
Specialists for any services furnished me by this provider. I authorize any holder of medical information about me to
release to my insurance company any information needed to determine these benefits or benefits payable for related
services.
Patient (Beneficiary) Signature________________________________Date________________
River Valley Infectious Disease Specialists
Health Information Consent
I give my consent to representatives of River Valley Infectious Disease Specialists to leave messages on my
home or cell phone answering system or with individuals that I will designate below.
Relating to my care
____ Yes
____ No
Appointments Reminders
____ Yes
____ No
I give my consent to representatives of River Valley Infectious Disease Specialists
to discuss my care with the following individuals:
________________________________
Spouse Name
________________________________
Family Member - Relationship
________________________________
Family Member - Relationship
_____/_____/_________
Phone No. w/area code
_____/_____/_________
Phone No. w/area code
_____/_____/_________
Phone No. w/area code
________________________________
_____/_____/_________
Other Name – Relationship
Phone No. w/area code
I understand and agree that this authorization will stay in effect until such time I give written notice to change or
withdraw my authorization.
Signature __________________________________________