<p> The New York Center for Travel and Tropical Medicine 110 East 55th Street New York, NY 10022 Phone: (212) 734-3000</p><p>TRAVEL FEE SCHEDULE</p><p>NAME DATE </p><p>$125 Pre-Travel Consult, Level I, per trip  $35 International Certificate of Vaccination (ICV)  $35 Phlebotomy (Blood Draw) </p><p>PER DOSE PRICE</p><p> $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</p><p>I ACKNOWLEDGE THAT I HAVE BEEN GIVEN THIS FEE SCHEDULE AND I WILL BE GIVEN THE OPPORTUNITY TO ASK QUESTIONS.</p><p>Print Name: ______Signature: ______TRAVEL QUESTIONNAIRE</p><p>Today’s Date______Referred by______</p><p> I am a returning patient</p><p>Name:______</p><p>Last First Middle Initial</p><p>Address: ______</p><p>Number, Street Apt #</p><p>______City State Zip Code</p><p>Telephone: Cell______Home______Work ______</p><p>Email address ______</p><p> Male  Female Date of Birth ______Age ______</p><p>Place of birth:  USA  Other (specify)______</p><p>Date you arrived in the US______</p><p>Emergency contact ______Phone # ______</p><p>Pharmacy Information: ______The New York Center for Travel and Tropical Medicine 110 East 55th Street New York, NY 10022 Phone: (212) 734-3000</p><p>*** 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</p><p>Physician’s Full Name ______First Name Last Name </p><p>Address: ______Number, Street Apt/Suite/Floor #</p><p>______City State Zip Code</p><p>Pertinent Medical and Surgical History ______</p><p>Current Medications ______</p><p>Are you being treated with any of the following? HUMIRA: YES NO EMBREL: YES NO ENTYVIO: YES NO </p><p>Do you have any history of Thymus Gland Disease or Myasthenia Gravis? YES NO ______</p><p>Medication/Food allergies: ______</p><p>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</p><p>Dates City and Country # Days in each location</p><p>Purpose of Trip  Vacation  Business  Other (please specify) </p><p>______</p><p>______Patient Signature Date</p>