Download QUALITY INTERNAL MEDICINE`s TRAVELER`S CLINIC

QUALITY INTERNAL MEDICINE’s TRAVELER’S CLINIC
1860 Town Center Drive Suite 255 Reston, VA 20190
Phone: 703 707 0607 Fax 703 707 0949
To serve the various travel-related needs of our patients, we offer specialized services
customized to any particular itinerary:
** Up-to-date information regarding disease and resistance patterns
**Customized recommendations regarding helpful vaccinations and other disease
prevention interventions that takes into account any personal medical conditions, allergic
or adverse reactions
**Useful health hints for the prevention and treatment of traveler’s diarrhea, altitude
sickness, motion sickness and other travel and recreation related health issues
**Up-to-date diplomatic warnings issued by the U.S. government regarding political and
other instabilities
Since this is considered an administrative type of exam that insurance typically does not
cover, we do not bill insurance companies for these services and thus expect full payment
at the time of your visit. The fee for this service is based on the following:
--amount of time needed to research a particular itinerary and any patient-specific issues
--amount of time needed to provide the necessary information and counseling to the
patient
--the vaccinations administered
Therefore, we ask that you sign below indicating an understanding of the above and that
benefits from a participating insurance company will be waived.
NAME: ________________________________________
SIGNATURE:___________________________________
DATE: ________________________________________
Quality Internal Medicine, PLLC
1860 Town Center Drive Suite 255
Reston, VA 20190
Phone: 703 707-0607
Fax: 703 707-2027
Traveler’s Clinic Registration
Name:
Address:
Phone Number:
Fax Number:
Itinerary (please specify exact arrival and departure dates to/from each place/country you
will be visiting):
Allergies:
Medications (over-the-counter and prescription, dosage):
Medical conditions:
You will be called to schedule an appointment for counseling and advice regarding
vaccinations and other prophylactic/preventive measures.