Pre-Travel Questionnaire

Please complete all fields for the following pre-travel questionnaire regarding you upcoming travels. After submitting, a member of the Student Health team will contact you within 2 business days to schedule your travel consultation. Make sure to include your phone information, since appointments must be scheduled over the phone due to HIPAA compliance.

Enter today''s date
Enter your full first and last name
Enter your date of birth
Enter the area code + phone number where we can contact you to schedule your appointment
Enter the date you are departing from Nashville, TN or other U.S. location

Itinerary

Select the destinations below to enter detailed trip information applicable for your travel consult.

Destination 1
Type n/a if not applicable.
Do you need to enter details for a second destination?
Destination 2
Type n/a if not applicable.
Do you need to enter details for a third destination?
Destination 3
Type n/a if not applicable.
Do you need to enter details for a fourth destination?
Destination 4
Type n/a if not applicable.
Do you need to enter details for a fifth destination?
Destination 5
Type n/a if not applicable.
Enter the Group Name or Specific Study Abroad Program- eg. CET, CIEE, IES Abroad, SIT(if applicable). Please review your program form for details. This helps us determine the length of your appointment and if a physical exam performed by an MD or NP is needed.
Enter the Group Leader (if applicable)
Activities
Check all that apply both work and recreational
Reason for Travel
Check all that apply
Accomodations
Check all that apply
Enter the pharmacy name, address, fax number, and phone number that you would like to pick up prescriptions (if necessary)
Appointment Availability
Enter your preferred day of the week and time for your Travel Consult. Note that Travel Consults are scheduled Monday - Friday, 8:00 a.m. - 3:30 p.m.