Travel Vaccines

Hometown care for world travelers.

Even if you’re headed to a faraway place, your hometown pharmacy is here to help you prepare.

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Travel Vaccines

Fill out this form so we can get you what you need.

Please fill out the online form below in its entirety. Once submitted, a pharmacist will contact you within 5 business days to finalize your appointment and review the recommended medications and vaccinations for your travel.

Most vaccinations need to be administered a minimum of 10-14 days prior to travel so we recommend scheduling your appointment at least 30 days prior.

Most Common Travel Vaccine/Medication Pricing

Traveler's Diarrhea Treatment
- Azithromycin 500 mg #2) – $5
Malaria Prophylaxis
- Doxycycline 100 mg – $0.50 per tablet
- Atovaquone/proguanil (Malarone) – $3 per tablet
Yellow Fever Vaccine
- YF-Vax – $250
Typhoid Fever Vaccine
- Typhim – $175

Travel Vaccination Request & Consent Form

Contact Information

Name(Required)

First Last

Date Of Birth(Required)

Phone(Required)

Email(Required)

Enter Email Confirm Email

Travel Itinerary

Please list the country and cities within each country that you will be traveling to. Arrival date is the date you will arrive in that country. Departure date is the date you will leave from that country.

1st Country(Required)

Arrival Date(Required)

Departure Date(Required)

2nd Country

Arrival Date

Departure Date

3rd Country

Arrival Date

Departure Date

4th Country

Arrival Date

Departure Date

5th Country

Arrival Date

Departure Date

About Your Travel

Purpose of Trip(Required)

School/study, pleasure, business, mission work, etc.

Accommodations(Required)

Indoor, A/C, screens, tents, open air, etc.

Planned Activities(Required)

Hiking, climbing, scuba diving, site seeing, working, night life, etc.

Is this your first trip abroad?(Required)

Yes

Will you potentially be exposed to blood or bodily fluids?(Required)

Yes

Will you potentially be exposed to farm or wild animals?(Required)

Yes

Requested Vaccinations / Medications

Our trained Kohll’s pharmacists will make recommendations based on your travel itinerary, but please list any vaccinations/medications you know you would like to receive.

Current Medical Information

Current Medical Conditions

Please list all current medical conditions and any recent surgeries.

Current Medications

Please list all current medications not currently filled at Kohll’s Rx.

Immunization / Vaccination History

Please bring in a copy of your immunization history to your appointment or fill out the following information with the dates of your previous immunizations.

Immunization Record Upload

Drop files here or

Accepted file types: jpg, jpeg, gif, tif, tiff, pdf, png, bmp, Max. file size: 10 MB.

Hepatitis A (Havrix, Vaqta) Date 1

Hepatitis A (Havrix, Vaqta) Date 2

Hepatitis B (Engerix) Date 1

Hepatitis B (Engerix) Date 2

Hepatitis B (Engerix) Date 3

Meningitis (Menactra)

Polio

Tdap (Boostrix)

Typhoid Fever (Vivotif, Typhim)

Influenza

MMR Date 1

MMR Date 2

HPV (Gardasil) Date 1

HPV Date 2

HPV Date 3

Yellow Fever (YF-Vax, Stamaril)

Japanese Encephalitis (Ixiaro)

Cholera (Vaxchora)

Other Vaccinations and Dates

Insurance Information

Medical

Insurance Provider

Member / Cardholder ID #

Group #

Pharmacy / Prescription

Insurance Provider

RxBIN

6 digit number, required for processing

PCN

Member / Cardholder ID #

RxGroup

Front of Prescription Insurance Card

Drop files here or

Accepted file types: jpg, jpeg, gif, tif, tiff, pdf, png, bmp, Max. file size: 10 MB.

Back of Prescription Insurance Card

Drop files here or

Accepted file types: jpg, jpeg, gif, tif, tiff, pdf, png, bmp, Max. file size: 10 MB.

Preferred Kohll's Rx Location

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Preferred Date To Receive Vaccination

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Preferred Time To Receive Vaccination

Preferred Kohll's Location To Receive Vaccination(Required)

Special Requests / Notes

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Patient Consent Form

In order to speed up the vaccination process, we ask that all vaccine recipients fill out our patient consent form before their appointment.

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Patient Consent Form

In order to speed up the vaccination process, we ask that all vaccine recipients fill out our patient consent form before their appointment.

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Date Of Birth

Sex

Male

Female

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Allergy and Health Information

Do you have any severe food or drug allergies?

Yes

Are you allergic to neomycin, streptomycin or polymyxin B?

Yes

Are you allergic to gelatin, eggs, chicken or chicken feathers?

Yes

Are you allergic to formaldehyde or 2-phenoxyethanol?

Yes

Are you allergic to latex, yeast or thiomersal?

Yes

Please list any allergies not mentioned above.

Have you ever had a severe reaction to any vaccine?

Yes

Do you have a substantial fever (>101.3°F), diarrhea or vomiting?

Yes

Do you have a weakened immune system? (because of diseases such as cancer, active TB, HIV or AIDS or because of immunosuppressive drug therapy such as that caused by high dose corticosteriods or radiation therapy)

Yes

Have you recently received blood plasma (i.e. immune globulin) transfusions/injections within the last 6 months?

Yes

Have you been on antibiotic therapy within the last 24 hours?

Yes

Have you received any vaccinations within the last 30 days?

Yes

Do you have a history of Guillain-Barre Syndrome?

Yes

Females Only

Are you pregnant or attempting to get pregnant?

Yes

Have you had a mastectomy?

Yes

Malaria Prophylaxis Recipients

Do you have eye disease or vision problems?

Yes

Do you have glucose 6-phosphate dehydrogenase (G6PD) deficiency?

Yes

Do you have hearing problems?

Yes

Do you have liver disease?

Yes

Do you have psoriasis?

Yes

Do you have a history of seizures (epilepsy or convulsions)?

Yes

Do you have depression or history of mental problems including anxiety disorder, schizophrenia, or psychosis?

Yes

Do you have heart disease?

Yes

Do you have stomach problems like colitis?

Yes

Do you have kidney disease?

Yes

While abroad will you have long exposure to sunlight (working outdoors)?

Yes

Traveler's Diarrhea Treatment Recipients

Do you have black or bloody stools?

Yes

Do you currently have bacterial food poising?

Yes

Do you have colitis or mucus in your stool?

Yes

Do you have liver disease?

Yes

Do you have severe abdominal pain, swelling or bulging?

Yes

Do you have a heart condition or irregular heartbeat?

Yes

Do you have kidney disease or diabetes mellitus?

Yes

Do you have seizure disorder?

Yes

Do you have myasthenia gravis or cerebral disease?

Yes

While abroad will you have long exposure to sunlight (working outdoors)?

Yes

Additional Questions

How did you hear about us?(Required)

How did you arrive on our website?(Required)

Google (direct link)

Bing (direct link)

Yahoo (direct link)

YellowPages.com

Yelp.com

Other

Do you understand the benefits of compression stockings?

Yes

Are you interested in purchasing a pair of compression stockings to wear during your flight?

Yes

Employer Sponsored Travel

If your employer is set up with us for direct billing of your travel vaccination costs, please select them from the list below. If they are not, feel free to put them in touch with us to get that set up.

Employer List

Oriental Trading Company (OTC)

Appointment & Consultation Fee

A non-refundable $50 consultation fee applies per person. A trained pharmacist reviews your submitted information, determines the recommended medications and vaccinations, and will answer any questions at the time of appointment. Due to the time required, the fee is non-refundable.

Forms submitted will not be addressed until payment is received.

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Would you like a pharmacist consultation to review CDC recommendations with you?(Required)

Personalized consultation fee of $45 per family applies.

YES

Additional Household Members

Please list any additional household/family members who will be traveling with you and participating in this consultation. Be sure to use the same names when submitting this form for each traveler.

A separate form must be submitted for each individual.

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Household Fee

The per-household consultation fee has already been paid and this information is being submitted for an additional member of the same household.

Payment Information

Personalized Consultation

$0.00

NE Sales Tax

$0.00

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Travel Vaccines

Hometown care for world travelers.

Travel Vaccines

Fill out this form so we can get you what you need.

Most Common Travel Vaccine/Medication Pricing

Travel Vaccination Request & Consent Form

Contact Information

Travel Itinerary

About Your Travel

Current Medical Information

Immunization / Vaccination History

Insurance Information

Medical

Pharmacy / Prescription

Preferred Kohll's Rx Location

Patient Consent Form

Allergy and Health Information

Females Only

Malaria Prophylaxis Recipients

Traveler's Diarrhea Treatment Recipients

Additional Questions

Employer Sponsored Travel

Appointment & Consultation Fee

Payment Information

Signature

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