Submitting this form is just one way to request an appointment. If you prefer, you may call the Travel Clinic and leave a message at 617-258-9355. We will return your call within three business days. First name Last Name Date of Birth MIT ID Number Phone number Email What are the dates of your travel? Estimated start date Estimated return date Does your destination country require a COVID-19 vaccination certificate with a QR code? Yes No Are you traveling for MIT-related business? Yes No Cost object number Will you be traveling to destinations with elevations greater than 8,000 ft. (2,500 meters)? Yes No List your proposed travel itinerary with specific destinations. Preferred appointment day: Monday Tuesday Wednesday Thursday Friday Check all that apply. Preferred appointment time: 8:30 –10 a.m. 10:30 a.m. – 12 p.m. 1 – 3 p.m. 3 – 4:30 p.m. Check all that apply. If you have not already done so, sign up for HealthELife, MIT Medical’s online patient portal. When you come to your first appointment, please bring any immunization records that are not already in your MIT Medical record. Leave this field blank
