Travel Clinic consultation request form

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 617-253-4488. We will return your call within two business days.

First Name *

Last Name *

Date of Birth *

Year

Month

Day

MIT ID Number

Phone number *

Email *

What are the dates of your travel?

Estimated start date

Year

Month

Day

Estimated return date

Year

Month

Day

Cost object number

Will you be traveling to destinations with elevations greater than 8,000 ft. (2,500 meters)? *

Yes

List your proposed travel itinerary with specific destinations. *

Travel Clinic consultation request form

When you come to your first appointment, please bring any immunization records that are not already in your MIT Medical record.