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Appointment Basics

Location

Number of travellers

Primary Traveller Information

Name(Required)

First Last

Date of Birth

Gender

Personal Healthcare Number

Family Doctor Name

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Additional Travellers

Name

First Last

Date of Birth

Personal Healthcare Number

Name

First Last

Date of Birth

Personal Healthcare Number

Name

First Last

Date of Birth

Personal Healthcare Number

Name

First Last

Date of Birth

Personal Healthcare Number

Travel Itinerary

Departure Date

Return Date

Destination(s)

Flight path & layovers

Duration of Trip

Trip Location

Urban

Rural

Beach

Altitude >3000m

Reason for travel

Tourism

Business

Visiting Family

Adventure

Cruise

Immigration

Voluntary/Charity

Elective/Student

Accommodation

Hotel

Camping

AirBnB

Cruise

Staying with Locals

Quality of Accommodation

Travel Risks & Activities

Planned Activities

Scuba Diving

Hiking

Animal Interactions

High-Altitude Travel

Extreme Sports

Medical & Vaccine History (Primary Traveller)

Existing Medical Conditions

Heart Condition

Liver/Kidney Disease

Diabetes

Seizures

Immunodeficiency

Autoimmune Disease

Check all that apply

Are you pregnant or currently breastfeeding

Yes

Current Medications

Allergies (medications, foods etc.)

Previous Reaction to Vaccines?

Yes

If yes, please specify

Past Travel-Related Illness?

Yes

If yes, please specify

Vaccination History (check all received)

Covid-19

Influenza

Hepatitis A/B

Typhoid

Yellow Fever

Japanese Encephalitis

Rabies

Other

Vaccination Records Available?

Yes

Alberta residents can obtain their immunization history by calling Alberta Health Link at 403.943.LINK (5465)

Medical & Vaccine History (2nd Traveller)

Existing Medical Conditions

Heart Condition

Liver/Kidney Disease

Diabetes

Seizures

Immunodeficiency

Autoimmune Disease

Check all that apply

Are you pregnant or currently breastfeeding

Yes

Current Medications

Allergies (medications, foods etc.)

Previous Reaction to Vaccines?

Yes

If yes, please specify

Past Travel-Related Illness?

Yes

If yes, please specify

Vaccination History (check all received)

Covid-19

Influenza

Hepatitis A/B

Typhoid

Yellow Fever

Japanese Encephalitis

Rabies

Other

Vaccination Records Available?

Yes

Alberta residents can obtain their immunization history by calling Alberta Health Link at 403.943.LINK (5465)

Medical & Vaccine History (3rd Traveller)

Existing Medical Conditions

Heart Condition

Liver/Kidney Disease

Diabetes

Seizures

Immunodeficiency

Autoimmune Disease

Check all that apply

Are you pregnant or currently breastfeeding

Yes

Current Medications

Allergies (medications, foods etc.)

Previous Reaction to Vaccines?

Yes

If yes, please specify

Past Travel-Related Illness?

Yes

If yes, please specify

Vaccination History (check all received)

Covid-19

Influenza

Hepatitis A/B

Typhoid

Yellow Fever

Japanese Encephalitis

Rabies

Other

Vaccination Records Available?

Yes

Alberta residents can obtain their immunization history by calling Alberta Health Link at 403.943.LINK (5465)

Medical & Vaccine History (4th Traveller)

Existing Medical Conditions

Heart Condition

Liver/Kidney Disease

Diabetes

Seizures

Immunodeficiency

Autoimmune Disease

Check all that apply

Are you pregnant or currently breastfeeding

Yes

Current Medications

Allergies (medications, foods etc.)

Previous Reaction to Vaccines?

Yes

If yes, please specify

Past Travel-Related Illness?

Yes

If yes, please specify

Vaccination History (check all received)

Covid-19

Influenza

Hepatitis A/B

Typhoid

Yellow Fever

Japanese Encephalitis

Rabies

Other

Vaccination Records Available?

Yes

Alberta residents can obtain their immunization history by calling Alberta Health Link at 403.943.LINK (5465)

Medical & Vaccine History (5th Traveller)

Existing Medical Conditions

Heart Condition

Liver/Kidney Disease

Diabetes

Seizures

Immunodeficiency

Autoimmune Disease

Check all that apply

Are you pregnant or currently breastfeeding

Yes

Current Medications

Allergies (medications, foods etc.)

Previous Reaction to Vaccines?

Yes

If yes, please specify

Past Travel-Related Illness?

Yes

If yes, please specify

Vaccination History (check all received)

Covid-19

Influenza

Hepatitis A/B

Typhoid

Yellow Fever

Japanese Encephalitis

Rabies

Other

Vaccination Records Available?

Yes

Alberta residents can obtain their immunization history by calling Alberta Health Link at 403.943.LINK (5465)

Insurance Information

Insurance Company

Carrier ID (2 digits)

Policy/Group Number

Client or Certificate ID

Card Holder Name

Upload a picture of your card

Max. file size: 100 MB.

Consent

Fee Consent

$50 Consult Fee | $20 Fee for Additional Travellers (minimum age of 2 years old)

Telehealth Consent

I authorize CurisRx Pharmacy to provide virtual care using phone or telecommunication for medication, compounding, and travel-related consultations. I understand that technical difficulties may occur and may affect communication. I understand that: I may withdraw my consent at any time, Telehealth sessions are not recorded, I may request a copy of this consent form, and I may ask questions at any time without affecting my future care.

Information Consent

I confirm that the information provided is accurate to the best of my knowledge.

Patient Name(Required)

First Last

Date

Confidentiality Disclaimer: All personal and health information collected during your travel health consultation is confidential and protected under the Personal Health Information Act (PHIA). This information will only be used for your health care needs and will not be shared without your consent, except as required by law.

We will reply to your request as soon as possible during business hours. If your inquiry is received after business hours, we will respond during our next business day.

Thank you for considering CurisRx Pharmacy.
We look forward to meeting you!

Messages sent using this form are not considered private. If you are sending highly confidential or private information, please contact our office by telephone at any one of our four locations at (825) 413-6202 for our Seton location, (403) 300-1407 for our Kingsland location, (403) 299-5808 for our Mahogany location, (403) 863-6535 for our Harmony location or (403) 701-2921 for our Trinity Hills location. Please review our privacy policy and website terms of use before submitting your form request.

Appointment Basics

Primary Traveller Information

Additional Travellers

Travel Itinerary

Travel Risks & Activities

Medical & Vaccine History (Primary Traveller)

Medical & Vaccine History (2nd Traveller)

Medical & Vaccine History (3rd Traveller)

Medical & Vaccine History (4th Traveller)

Medical & Vaccine History (5th Traveller)

Insurance Information

Consent

Thank you for considering CurisRx Pharmacy. We look forward to meeting you!

Thank you for considering CurisRx Pharmacy.
We look forward to meeting you!