HomeAbout UsOccupational HealthTravel HealthFire CompanyAsbestos ServicesAdditional ServicesContact Us General Visit Form PRINT NOW Please fill out the form below prior to your visit, OR print this form and bring to your visit. Patient Demographics Sex: Male Female Information About Trip Previous Travel Vaccinations (list year they were received) Please list any adverse reactions to previous vaccinations: Allergies Please check yes or no and explain all “yes” answers: Arthritis / Joint Pain Yes Asthma / Hayfever / Allergic Rhinitis Yes Bleeding Tendency / Blood Thinners Yes Depression / Anxiety / Panic Attacks Yes Diabetes Yes Eczema or Psoriasis Yes Heart Disease / Surgery / Pacemaker Yes High Blood Pressure Yes Immune Disorder Yes Impaired Vision or Hearing Yes Jaundice or Hepatitis Yes Muscle or Bone Disease Yes Nervous System Disorder Yes Renal (Kidney) Disease Yes Respiratory (Lung) Disease Yes Seizures / Convulsions / Fainting Yes Sickle Cell Anemia Yes Stomach Ulcers / Heartburn / Reflux Yes Surgery or Hospitalization in past 3 years Yes Thymus Gland Disorder Yes Thyroid Disease or Goiter Yes Tuberculosis Yes Have you been treated for illness or injury in the past 2 years? Yes Thank you for choosing Great Lakes Physician Services for your travel immunization needs. At your visit, our experienced providers will consult with you regarding the vaccinations that you are requesting. If you are traveling abroad, our providers will discuss with you all the information you need to help you stay healthy during you trip. Please be aware that we DO NOT participate with any insurance companies. Once you meet with our provider and determine which immunizations you will be receiving, you will be expected to pay for those immunizations along with an office visit fee. If you need to return to complete a series of shots (i.e. Hepatitis B), you will only be charged one office visit fee for the entire series. For family members or small groups that come in together ,there will only be one office visit fee assessed (1-3 people fee is $50, 4-6 people fee is $60, 6 and over will start at $75 but will be determined by size of group. We accept Visa, Master Card, or Cash as means of payment. At the time of payment, you will be provided with itemized receipts that contain all of the information that you will need for insurance submission purposes. We cannot guarantee that your insurance provider will reimburse any of your costs for these services. The amount reimbursed to you, if any, is dependent upon you’re the terms of your insurance plan. I have read and understand the above payment terms: 462 Grider Street, Suite 116 Buffalo, NY 14215 716.898.4153 Health Services Occupational Health Fire Company Travel Health Asbestos Forms General Visit All Forms Reference Links OSHA NYS Workers Comp AOHP View More... Website by NK4Design