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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.