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Calgary Co-op Pharmacy Travel Health Clinic

Please bring to your appointment: Vaccination records (childhood/travel), travel itinerary and prescription drug coverage. Vaccines, medications and other travel recommendations will be tailored to suit your needs based on your responses. Please return form at least 48 hours prior to appointment.

Please complete one questionnaire per traveler

Do you have direct bill insurance for medications/prescriptions?  If yes, bring the insurance card and proceed to the pharmacy 10 minutes prior to your appointment to have the information entered. 

Pre-Travel Questionnaire

Emergency Contact
Please list all cities and countries you will visit (including stopovers) during your trip. List areas in order of travel itinerary.
Purpose of Trip
Activities (Check all that apply)
Do you have Travel Health Insurance?
Travel Experience
Do you have (or have you had) any of the following medical conditions?
Allergies and other Reactions (describe reaction)
Needle Anxiety
Fainting
Alberta residents can obtain their Immunization history by calling Alberta Health Link at (403)-943-LINK
Please indicate which of the following vaccines you have had
Did you have any of the following diseases in your childhood?
Immunizations
Did you receive childhood vaccinations?
Have you received any vaccines in the past 4 weeks?
For women:
Are you pregnant?
Are you breastfeeding?
Birth Control?

We will contact you within 24-48 hours to confirm your appointment 

Consult Fees: Single: $60 Couple: $110 Family (max 4): $150
Please visit www.calgarycoop.com/pharmacy for more details

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Calgary Co-op Forms Travel Health Clinic Information
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