Travel Medical History Questionnaire

Submit Your Trip Details

Please be advised that currently we do not have access to the Yellow Fever Vaccine.

Whether you’re going on a vacation, safari, mission trip, semester abroad, business trip, or inter-country adoption, MedSpring is your one-stop urgent care medical center to assist you and your family on your journey.

Simply fill out a Travel Medical History Questionnaire to give us details of your trip. A MedSpring provider will review your questionnaire and call you to schedule a visit. During that visit, you will consult with one of our providers to receive your personalized health plan, that includes vaccinations, medication, etc.

PLEASE LIST ALL YOUR CURRENT MEDICATIONS (Include prescriptions, over-the-counter, supplements and eye drops)

Confirmation of submitted details

The above information is complete and accurate to the best of my knowledge. I hereby consent to consultation and treatment / administration of vaccines by the provider. I understand that payment in full by cash or credit card is due at the time of the visit. ChoiceOne Urgent Care does not bill insurance or any third party payor, including Medicare. A portion of the charges may be reimbursable by insurance.

By submitting this form, you agree to our Terms of Use

All data submitted is protected and secured using the highest standards required under HIPAA.