Medical Intake Form

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

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.

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