PreTravel - Travel Wellness Clinic

Travel Details

This form will take approximately 15 minutes to complete.

Contact First Name:

Contact Last Name:

Street Address:

City:

Province:

Postal Code:

Phone #:

Departure Date:

Return Date:

Appointment Location:

Destinations (in order). Please include airport stop overs:

Nature Of Travel (check all that apply):

Type of accomodations (check all that apply):

Other:

Travel companion(s):

Modes of travel (check all that apply):

Other:

Activities planned (check all that apply):

Other:

Previous international travel experience:

Yes No