TEXAS HILLS URGENT CARE CENTERS Pre-Travel Consult Appointment Request

These forms will be submitted electronically to Texas Hills Urgent Care Centers. Upon arrival, a valid driver’s license, military ID card, or other form of picture ID must be presented. In general, health insurance does not cover the cost of travel medicine services or pre-travel vaccinations. Most insurance consider this an elective expense that you are taking on yourself. If you wish to attempt to file a claim with your insurance, we will provide you with an itemized statement of your expenses, but we do not file health insurance claims for Travel Medicine Services.

For any questions about costs of services or directions to the clinic, please visit our website (www.thucc.com) or call either 830-798-1122 for our Marble Falls office or 512-250-8199 for our Cedar Park Office.

While we will attempt to see you as close to your scheduled time as possible and expedite your visit, please keep in mind, Texas Hills Urgent Care is an Urgent Care Center. There are occasions when seriously ill or injured patients may take priority. Even with the occasional delay, our evening and weekend hours have made travel preparation convenient for countless travelers to all corners of the world.

* Which facility would be most convienent to you for this visit?

* What is your Approximate Travel Date of Departure?

* What is the reason for this Pre-Travel Visit?

Physician Office Consult and Vaccinations

Vaccinations only, I have done/plan to do an Online Pre-Travel Consult

Vaccinations only, I have discussed my travel plans in detail with my regular doctor and I have a written order for vaccines from my doctor

If you are having your physician order your travel vaccines, it is you and your physician's responsibility to ensure that you are receiving the correct vaccines for your destination and any other appropriate medications (e.g. malaria, travelers diarrhea medications) needed for safe travel to and from your destination and during your stay. Texas Hills Urgent Care strongly encourages you to complete a online travel consult or to do an in-office travel consult with our physician who is trained and experienced in making recommendations for international travel.

* Please confirm that you have read and understand the above statement.

I agree and accept

Patient Information

* Last Name

* First Name

* Middle Initial

* Birthdate (M/D/Y)

Social Security #

* Gender

* Marital Status

* Race

* Ethnicity

* Preferred Language

* Home Phone

Cell Phone

* Email Address

* Street Address

* City

* State

* Zip Code

Mailing Address Info (if different)

* Employer Name

* Employer Phone

* Employer Address (street address, city, state and zip please)

* Preferred Method Of Communication:

Responsible Party Information

Same as Patient

Responsible Last Name

First Name

Middle Initial

Birthdate (M/D/Y)

Social Security #

* Home Phone

Cell Phone

Mailing Address

City

State

Zip Code

Relationship to Patient

Employer Name

Employer Phone

Employer Address (street address, city, state and zip please)

* Name of Emergency Contact

* Emergency Contact Phone #

* How Did You Hear About Us ?

Enter other referral source

* Indicates Response Required