Travel Questionnaire

The payment for services rendered is due at the time of service by credit card, cash, or check. We will file insurance claims, but only upon your specific request. If we receive any payment from your insurance company, we will forward all monies to you.

I as a patient/legal guardian, consent to the medical services listed in the table above. I also have had opportunity to review Rocky Mountain Infectious Diseases notice of privacy practices which are available upon request.

The above information is accurate to the best of my knowledge. I understand that I will be given an immunization record listing all vaccines received and that I am responsible for keeping this safe and up-to-date. Inactive records are kept on file for 3 years at the RMID Travel Medicine Clinic and are confidential.