Whether for business, study, or vacation, AFC Urgent Care Bronx is dedicated to keeping you safe and healthy – no matter where you are. Our experienced physicians are trained to provide comprehensive medical information, travel immunizations, medications, and other healthcare services that are customized to your needs to help prevent travel-related illness or disease.

It’s important to make any medical preparations well in advance when traveling internationally. Some vaccinations require multiple doses, given weeks or months apart. To expedite your care and ensure your safety, AFC Urgent Care has set up an online questionnaire for you to complete prior to your visit. We will then customize an immunization program for you based on the information you provide to protect you against a wide range of illnesses.

Our easy, affordable travel medicine program includes a variety of comprehensive health care services:

  • Vaccinations
  • Anti-Malaria
  • Anti-Diarrhea
  • Physicals
  • Altitude Sickness
  • Motion Sickness

 

Complete the form below to get started on your vaccinations.  For more information about our travel medicine program, please contact either of our Bronx locations:

  • 843 Hutchinson River Parkway, Bronx, NY | 718-925-4400
  • 332 East 149th St., Bronx, NY 10451 | 347-329-4010

 

***Please note that you must consult with your insurance provider to determine coverage for travel vaccines as it can vary from provider to provider.***

 

Name

Sex

Date of Birth (MM/DD/YYYY)

Phone

Email

Your Destination

Dates of Trip

Purpose of Your Trip

Are you currently treated for any medical problems?

Have you has a significant medical problem in the past?

Could you be pregnant?

Are you staying mostly in cities/tourist destinations?

Are you going to spend time in a rural area?

Are you going to spend time above 5000 ft?

Are you going to work in the foreign country?

Are you allergic to eggs or chicken products?

Have you has any hypersensitivity or reaction to vaccinations?

Have you had Guillain-Barre Syndrome?

Have you had all of your childhood vaccinations?

Have you had tetanus/diphtheria vaccination in the last 10 years?

Have you had measles vaccination (2 shots)?

Have you had polio vaccination as an adult?

Have you had hepatitis A vaccination (2 shots)?

Have you had hepatitis B vaccination (3 shots)?

Have you had meningitis vaccination in the past 3 years?

Have you had typhoid vaccination in the past 2 yeats (if injected), or in the past 5 years (if oral)?

Have you had yellow fever vaccination in the past 10 years?

Have you had Japanese encephalitis vaccination in the past 2 years?

List current or previous significant medical conditions

List current medications

Comments/Questions