Get Client Intake Form - Passport Health

The Client Intake Form - Passport Health is an essential document that gathers important information to provide tailored health advice and services for travelers. This guide will assist users in accurately completing the form with clarity and ease.

Follow the steps to effectively fill out the Client Intake Form.

1. Click the ‘Get Form’ button to access the Client Intake Form and open it in the online editor.
2. Begin by filling out your name in the designated fields for your last name, first name, and middle initial. Ensure that your entries are clear and legible.
3. Provide your complete address, including street, city, state, and zip code. Double-check for accuracy to avoid any discrepancies.
4. Indicate the current date and your birthdate by filling in the month, date, and year along with your age and sex, using the provided checkboxes.
5. Enter both your home and cell phone numbers, and include the last four digits of your Social Security number.
6. Answer whether you have visited Passport Health before, and if so, provide the previous visit date.
7. List your current employer and the work phone number for any necessary contact.
8. You have the option to register for free updates by checking yes or no and providing your email address.
9. Complete the section for your primary care physician’s name, contact number, and address. Indicate if you want a copy of your immunization record sent to them.
10. Specify the countries you will be traveling to and the approximate length of stay in each location, along with your departure and return dates.
11. Disclose any chronic physical or mental illnesses, allergies, and recent vaccinations. Provide additional details in the space provided.
12. Review the declaration at the end of the form confirming that your information is accurate. Sign the form as the traveler, parent, or guardian.
13. Finally, save any changes made, and download or print the form for your records. Make sure to share it as needed.

Complete the Client Intake Form online today to ensure a smooth travel health experience.