Voyage Medical

  • 2402 S. Rural Rd. Suite 101 Tempe, AZ. 85282
  • 24/7 Chat
  • 480-306-5000
  • info@voyagemedical.com
Medical Intake Form

Medical History and Patient Information

Gender
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Emergency Contact

Allergies

Do you have any known drug allergies?
Did you ever have a reaction to a vaccine?
YesNo
Eggs
Insect stings
Thimerosal
Gelatin
Latex
Yeast
Mercury
Formaldehyde
YesNo
Cancer
Contact Dermatitis
Heart disease
Acid Reflux
Anxiety
Arthritis
Diabetes
Eczema/Psoriasis
Epilepsy
Gastrointestinal disease
Guillain-Barre
Headaches
Hepatitis
HIV/AIDS
Hypertension
Kidney disease
Liver disease
Migraines
Neurological disease
Psychiatric condition
Rheumatoid Arthritis
Thymus Removal
Thyroid disease
Tuberculosis
YesNo
Are you receiving radiation or cancer treatments?
Do you have a history of fainting with immunizations?
Are you caring for someone who is immunocompromised?
Are you receiving steroid medications (prednisone/cortisone)?
Have you ever had a positive TB skin test?
Do you have cardiac issues or arrhythmia/irregularity?
Are you taking anticoagulants, aspirin? Do you have bleeding problems?
Do you experience nightmares or insomnia?
Do you have a previous history of tendonitis/tendon rupture?
Do you have bowel conditions such as diarrhea/constipation?
Are you currently experiencing respiratory issues like infections or any other acute illness/infection?
In the last 3 months, have you received blood transfusions or plasma transfusions? Have you been given an immune globulin, received any LIVE vaccine like MMR, Yellow Fever, Varivax (chickenpox), Flumist or Zostavax (shingles) in the last 3 months?
Have you ever had chickenpox?
Have you taken Malaria pills?
In the last month, did you receive any vaccines?
List all the vaccines with dates you received in the past:
Vaccine 1
 
List all medications you are currently taking:
Medicine 1
Medicine 2
Medicine 3
 
YesNo
Are you on birth control?
Are you currently pregnant?
Are you planning to become pregnant in the next three months?
Are you breastfeeding?

Travel Information

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Countries you will be visiting
Country
Length of stay
 
Activities

Release of Records Consent

I authorize Voyage Medical to release my protected health information (PHI) with the people and/or companies listed below. This authorization is ongoing. I may cancel this at any time by submitting a written request to Voyage Medical.
Self Consent
Other Entity

Please fill out the information below if you selected “Yes” to release your records to another entity (physician, health department, employer, family member, etc.)

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Clinical Research Consent

Are you being treated for any of the following?
Do you smoke?

Client Acknowledgement: I agree that the above information is accurate to my best recollection. By signing this consent I agree to be included into Voyage Medical’s Patient Database for Clinical Research. I understand that I can opt-out of this at any time. Voyage Medical may reach out to me via phone or email for participation in clinical trials.

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Client Acknowledgement

The above information is accurate to my best recollection. I understand that insurance may not cover travel vaccination services and that I am responsible for ALL fees associated with this visit at Voyage Medical. Payment is due at the time of appointment and service by debit or credit card. I have consented to all vaccines received. I understand I will receive documentation of all vaccines received and am responsible for keeping the record up-to-date and in a safe place. Voyage Medical keeps active records on file. Inactive records are kept on file in accordance with the state law.

All appointments at Voyage Medical incur an office visit/vaccination administration fee. This is in addition to the charge of each vaccine, medications, and other individual items purchased.

If you are receiving the yellow fever vaccine and you are over the age of 60, please check with your primary care provider to ensure you are healthy to receive the yellow fever vaccine as you may be required to provide permission from them.

If you have your immunization records, please bring them with you so a Travel RN Specialist can review them.

Voyage Medical has the right to charge a non-refundable fee of $50 for cancelling less than a 48 hours notice, or for missing an appointment. If you need to cancel or reschedule your appointment, please call 480-306-5000.

Voyage Medical Address:

2402 S Rural Rd Ste 101, Tempe, AZ 85282
Crossroads are Broadway Rd and Rural Rd

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Voyage Medical takes pride in advancing research. We are conducting a wide range of clinical studies. Make a difference and join us on our quest for better research. Clinical Research Tempe, Clinical Research Ahwatukee, Clinical Research Cave Creek, Clinical Research Chandler, Clinical Research Fountain Hills, Clinical Research Gilbert, Clinical Research Glendale, Clinical Research Maricopa, Clinical Research Mesa, Clinical Research Paradise Valley, Clinical Research Peoria, Clinical Research Phoenix, Clinical Research Queen Creek, Clinical Research San Tan Valley, Clinical Research Scottsdale, Clinical Research Sun City, Clinical Research Surprise, Clinical Research Tempe, Clinical Research Tucson, Clinical Research Yuma, Clinical Research Near Me

Clinical Trials Tempe, Clinical Trials Ahwatukee, Clinical Trials Cave Creek, Clinical Trials Chandler, Clinical Trials Fountain Hills, Clinical Trials Gilbert, Clinical Trials Glendale, Clinical Trials Maricopa, Clinical Trials Mesa, Clinical Trials Paradise Valley, Clinical Trials Peoria, Clinical Trials Phoenix, Clinical Trials Queen Creek, Clinical Trials San Tan Valley, Clinical Trials Scottsdale, Clinical Trials Sun City, Clinical Trials Surprise, Clinical Trials Tempe, Clinical Trials Tucson, Clinical Trials Yuma, Clinical Trials Near Me

We conduct a diverse array of Clinical Trials and Research for medications and medical conditions. We have experience Covid-19 trials, Diabetic trials and more. Dementia Trial Tempe, Dementia Trial Ahwatukee, Dementia Trial Cave Creek, Dementia Trial Chandler, Dementia Trial Fountain Hills, Dementia Trial Gilbert, Dementia Trial Glendale, Dementia Trial Maricopa, Dementia Trial Mesa, Dementia Trial Paradise Valley, Dementia Trial Peoria, Dementia Trial Phoenix, Dementia Trial Queen Creek, Dementia Trial San Tan Valley, Dementia Trial Scottsdale, Dementia Trial Sun City, Dementia Trial Surprise, Dementia Trial Tempe, Dementia Trial Tucson, Dementia Trial Yuma, Dementia Trial Near Me

If you’re looking for a study in which you’d like to participate, you’ve come to the right place. Hypertension Trial Tempe, Hypertension Trial Ahwatukee, Hypertension Trial Cave Creek, Hypertension Trial Chandler, Hypertension Trial Chandler, Hypertension Trial Fountain Hills, Hypertension Trial Gilbert, Hypertension Trial Glendale, Hypertension Trial Maricopa, Hypertension Trial Mesa, Hypertension Trial Paradise Valley, Hypertension Trial Peoria, Hypertension Trial Phoenix, Hypertension Trial Queen Creek, Hypertension Trial San Tan Valley, Hypertension Trial Scottsdale, Hypertension Trial Sun City, Hypertension Trial Surprise, Hypertension Trial Tempe, Hypertension Trial Tucson, Hypertension Trial Yuma, Hypertension Trial Near Me 

Covid-19 Trial Tempe, Covid-19 Trial Ahwatukee, Covid-19 Trial Cave Creek, Covid-19 Trial Chandler, Covid-19 Trial Chandler, Covid-19 Trial Fountain Hills, Covid-19 Trial Gilbert, Covid-19 Trial Glendale, Covid-19 Trial Maricopa, Covid-19 Trial Mesa, Covid-19 Trial Paradise Valley, Covid-19 Trial Peoria, Covid-19 Trial Phoenix, Covid-19 Trial Queen Creek, Covid-19 Trial San Tan Valley, Covid-19 Trial Scottsdale, Covid-19 Trial Sun City, Covid-19 Trial Surprise, Covid-19 Trial Tempe, Covid-19 Trial Tucson, Covid-19 Trial Yuma, Covid-19 Trial Near Me