The New York Center for Travel and Tropical Medicine
Total Page：16
File Type：pdf, Size：1020Kb
The New York Center for Travel and Tropical Medicine 110 East 55th Street New York, NY 10022 Phone: (212) 734-3000
TRAVEL FEE SCHEDULE
NAME DATE
$125 Pre-Travel Consult, Level I, per trip $35 International Certificate of Vaccination (ICV) $35 Phlebotomy (Blood Draw)
PER DOSE PRICE
$90 Polio (IPV) $85 Tetanus/Diphtheria/Pertussis (TdaP) $95 Typhoid: Typhim Vi $95 Hepatitis A (series of 2 @ $95 each) $95 Hepatitis B (series of 3 or 4 @ $95 each) $155 Hepatitis A&B combination (Twinrix) (series of 3 or 4) $195 Yellow Fever $165 Meningococcal (Menveo) $325 Gardasil (HPV) $325 Rabies ( pre-exposure series of 3 doses) $315 Japanese Encephalitis (series of 2 doses) $185 Pneumococcal: Pneumovax or Prevnar-13 $55 Influenza, quadrivalent or high dose $265 Cholera Oral Vaccine
I ACKNOWLEDGE THAT I HAVE BEEN GIVEN THIS FEE SCHEDULE AND I WILL BE GIVEN THE OPPORTUNITY TO ASK QUESTIONS.
Print Name: ______Signature: ______TRAVEL QUESTIONNAIRE
Today’s Date______Referred by______
I am a returning patient
Name:______
Last First Middle Initial
Address: ______
Number, Street Apt #
______City State Zip Code
Telephone: Cell______Home______Work ______
Email address ______
Male Female Date of Birth ______Age ______
Place of birth: USA Other (specify)______
Date you arrived in the US______
Emergency contact ______Phone # ______
Pharmacy Information: ______The New York Center for Travel and Tropical Medicine 110 East 55th Street New York, NY 10022 Phone: (212) 734-3000
*** IF YOU WOULD LIKE A FOLLOW-UP LETTER SENT TO YOUR PRIMARY CARE PHYSICIAN/REFERRING DOCTOR, PLEASE COMPLETE SECTION BELOW I do not wish to have a report sent to my physician I do not have a physician
Physician’s Full Name ______First Name Last Name
Address: ______Number, Street Apt/Suite/Floor #
______City State Zip Code
Pertinent Medical and Surgical History ______
Current Medications ______
Are you being treated with any of the following? HUMIRA: YES NO EMBREL: YES NO ENTYVIO: YES NO
Do you have any history of Thymus Gland Disease or Myasthenia Gravis? YES NO ______
Medication/Food allergies: ______
Egg allergy YES NO Guillain-Barre Syndrome YES NO Could you be pregnant now? YES NO Are you planning to become pregnant? YES NO Travel Details I am not traveling
Dates City and Country # Days in each location
Purpose of Trip Vacation Business Other (please specify)
______
______Patient Signature Date