Travel Vaccines

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 – $215
Typhoid Fever Vaccine
- Typhim – $150

Contact Information
Name*
First Last
Date Of Birth*
MM slash DD slash YYYY
Phone*
Email*
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*
Arrival Date*
MM slash DD slash YYYY
Departure Date*
MM slash DD slash YYYY
2nd Country
Arrival Date
MM slash DD slash YYYY
Departure Date
MM slash DD slash YYYY
3rd Country
Arrival Date
MM slash DD slash YYYY
Departure Date
MM slash DD slash YYYY
4th Country
Arrival Date
MM slash DD slash YYYY
Departure Date
MM slash DD slash YYYY
5th Country
Arrival Date
MM slash DD slash YYYY
Departure Date
MM slash DD slash YYYY
About Your Travel
Purpose of Trip*
School/study, pleasure, business, mission work, etc.
Accommodations*
Indoor, A/C, screens, tents, open air, etc.
Planned Activities*
Hiking, climbing, scuba diving, site seeing, working, night life, etc.
Is this your first trip abroad?*
- Yes
- No
Will you potentially be exposed to blood or bodily fluids?*
- Yes
- No
Will you potentially be exposed to farm or wild animals?*
- Yes
- No
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)
MM slash DD slash YYYY
Hepatitis A (Havrix, Vaqta)
MM slash DD slash YYYY
Hepatitis B (Engerix)
MM slash DD slash YYYY
Hepatitis B (Engerix)
MM slash DD slash YYYY
Hepatitis B (Engerix)
MM slash DD slash YYYY
Meningitis (Menactra)
MM slash DD slash YYYY
Polio
MM slash DD slash YYYY
Tdap (Boostrix)
MM slash DD slash YYYY
Typhoid Fever (Vivotif, Typhim)
MM slash DD slash YYYY
Influenza
MM slash DD slash YYYY
MMR
MM slash DD slash YYYY
MMR Date 2
MM slash DD slash YYYY
HPV (Gardasil)
MM slash DD slash YYYY
HPV Date 2
MM slash DD slash YYYY
HPV Date 3
MM slash DD slash YYYY
Yellow Fever (YF-Vax, Stamaril)
MM slash DD slash YYYY
Japanese Encephalitis (Ixiaro)
MM slash DD slash YYYY
Cholera (Vaxchora)
MM slash DD slash YYYY
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
Hidden
Preferred Date To Receive Vaccination
MM slash DD slash YYYY
Hidden
Preferred Time To Receive Vaccination

: Hours

Minutes

AM/PM
Preferred Kohll's Location To Receive Vaccination*
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.
- Show Form
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.
Hidden
Date Of Birth
MM slash DD slash YYYY
Sex
- Male
- Female
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Do you have any severe food or drug allergies?
- Yes
- No
Are you allergic to neomycin, streptomycin or polymyxin B?
- Yes
- No
Are you allergic to gelatin, eggs, chicken or chicken feathers?
- Yes
- No
Are you allergic to formaldehyde or 2-phenoxyethanol?
- Yes
- No
Are you allergic to latex, yeast or thiomersal?
- Yes
- No
Please list any allergies not mentioned above.
Have you ever had a severe reaction to any vaccine?
- Yes
- No
Do you have a substantial fever (>101.3°F), diarrhea or vomiting?
- Yes
- No
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
- No
Have you recently received blood plasma (i.e. immune globulin) transfusions/injections within the last 6 months?
- Yes
- No
Have you been on antibiotic therapy within the last 24 hours?
- Yes
- No
Have you received any vaccinations within the last 30 days?
- Yes
- No
Do you have a history of Guillain-Barre Syndrome?
- Yes
- No
Females Only
Are you pregnant or attempting to get pregnant?
- Yes
- No
Have you had a mastectomy?
- Yes
- No
Malaria Prophylaxis Recipients
Do you have eye disease or vision problems?
- Yes
- No
Do you have glucose 6-phosphate dehydrogenase (G6PD) deficiency?
- Yes
- No
Do you have hearing problems?
- Yes
- No
Do you have liver disease?
- Yes
- No
Do you have psoriasis?
- Yes
- No
Do you have a history of seizures (epilepsy or convulsions)?
- Yes
- No
Do you have depression or history of mental problems including anxiety disorder, schizophrenia, or psychosis?
- Yes
- No
Do you have heart disease?
- Yes
- No
Do you have stomach problems like colitis?
- Yes
- No
Do you have kidney disease?
- Yes
- No
While abroad will you have long exposure to sunlight (working outdoors)?
- Yes
- No
Traveler's Diarrhea Treatment Recipients
Do you have black or bloody stools?
- Yes
- No
Do you currently have bacterial food poising?
- Yes
- No
Do you have colitis or mucus in your stool?
- Yes
- No
Do you have liver disease?
- Yes
- No
Do you have severe abdominal pain, swelling or bulging?
- Yes
- No
Do you have a heart condition or irregular heartbeat?
- Yes
- No
Do you have kidney disease or diabetes mellitus?
- Yes
- No
Do you have seizure disorder?
- Yes
- No
Do you have myasthenia gravis or cerebral disease?
- Yes
- No
While abroad will you have long exposure to sunlight (working outdoors)?
- Yes
- No
Additional Questions
How did you hear about us?*
- Online Search
- Email
- Facebook
- Newspaper
- Radio
- Word Of Mouth
How did you arrive on our website?*
- Google (direct link)
- Bing (direct link)
- Yahoo (direct link)
- YellowPages.com
- Yelp.com
Do you understand the benefits of compression stockings?
- Yes
- No
Are you interested in purchasing a pair of compression stockings to wear during your flight?
- Yes
- No
Appointment & Consultation Fee
A non-refundable $25 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.
Hidden
Would you like a pharmacist consultation to review CDC recommendations with you?*
Personalized consultation fee of $45 per family applies.
- YES
- NO
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.
Hidden
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
Personalized Consultation
$0.00
NE Sales Tax
$0.00
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Signature
Signature
File
Max. file size: 300 MB.
Phone
This field is for validation purposes and should be left unchanged.

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

Females Only

Malaria Prophylaxis Recipients

Traveler's Diarrhea Treatment Recipients

Additional Questions

Appointment & Consultation Fee

Payment Information

Signature

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