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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 – $300
  • Typhoid Fever Vaccine
    • Typhim – $200

Travel Vaccination Request & Consent Form

Contact Information

Name(Required)
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Email(Required)

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.
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About Your Travel

School/study, pleasure, business, mission work, etc.
Indoor, A/C, screens, tents, open air, etc.
Hiking, climbing, scuba diving, site seeing, working, night life, etc.
Is this your first trip abroad?(Required)
Will you potentially be exposed to blood or bodily fluids?(Required)
Will you potentially be exposed to farm or wild animals?(Required)
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

Please list all current medical conditions and any recent surgeries.
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.
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    Insurance Information

    Medical

    Pharmacy / Prescription

    6 digit number, required for processing
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      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 Time To Receive Vaccination
        :
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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.

        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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        Select date MM slash DD slash YYYY
        Sex
        Address

        Allergy and Health Information

        Do you have any severe food or drug allergies?
        Have you ever had a severe reaction to any vaccine?
        Do you have a substantial fever (>101.3°F), diarrhea or vomiting?
        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)
        Have you recently received blood plasma (i.e. immune globulin) transfusions/injections within the last 6 months?
        Have you been on antibiotic therapy within the last 24 hours?
        Have you received any vaccinations within the last 30 days?
        Do you have a history of Guillain-Barre Syndrome?

        Malaria Prophylaxis Recipients

        Do you have eye disease or vision problems?
        Do you have glucose 6-phosphate dehydrogenase (G6PD) deficiency?
        Do you have hearing problems?
        Do you have liver disease?
        Do you have psoriasis?
        Do you have a history of seizures (epilepsy or convulsions)?
        Do you have depression or history of mental problems including anxiety disorder, schizophrenia, or psychosis?
        Do you have heart disease?
        Do you have stomach problems like colitis?
        Do you have kidney disease?
        While abroad will you have long exposure to sunlight (working outdoors)?

        Traveler's Diarrhea Treatment Recipients

        Do you have black or bloody stools?
        Do you currently have bacterial food poising?
        Do you have colitis or mucus in your stool?
        Do you have liver disease?
        Do you have severe abdominal pain, swelling or bulging?
        Do you have a heart condition or irregular heartbeat?
        Do you have kidney disease or diabetes mellitus?
        Do you have seizure disorder?
        Do you have myasthenia gravis or cerebral disease?
        While abroad will you have long exposure to sunlight (working outdoors)?

        Additional Questions

        How did you hear about us?(Required)

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

        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

        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.
        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

        Payment Information

        $50.00
        $3.50
        Credit Card(Required)
        American Express
        Discover
        MasterCard
        Visa
        Supported Credit Cards: American Express, Discover, MasterCard, Visa
        Expiration Date
         

        Signature

        Clear Signature

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