To schedule your appointment:

Fill out the appointment form below. Dr. Rose will contact you by return e-mail within 24 hours and inform you what disease risks you may encounter on your trip, which vaccines/medications are recommended and the cost of the consultation.

If you decide to schedule an appointment, please use the link to our scheduling website, which will be in Dr. Rose's return email to you.

Consultations at the Travel Clinic are generally scheduled on Monday, Wednesday and Friday between 10:00am and 4:00pm, but other times can work, especially if you are leaving on short notice. If family or friend(s) are traveling with you, please provide name(s) and DOBs in the space provided below.

Feel free to call Dr. Rose at 413-584-9254 if you have any immediate questions, are departing imminently, or need a priority appointment.

Your Name: *

Please indicate additional people in the Comments section at the bottom.

Your Date of Birth: * / /
Contact Information: *


*
What is the name of your doctor or Health Care Provider?
Preferred Contact Method: * Home Phone
Work Phone
Mobile Phone
Email
Address:
Travel Dates:
Please list the countries you plan to visit: *
Have you previously traveled to any of these countries?: Yes
No
To any tropical regions?: Yes
No

Have you been immunized previously to …

Hepatitus A: * Yes
No
Not Sure
Typhoid: * Yes
No
Not Sure
Yellow Fever: * Yes
No
Not Sure

Thank you for your inquiry. The Travel Clinic is open after 10 AM on Mondays, Wednesdays and Fridays. Please select several preferred date(s) and time(s) and we will contact you within 24 hours to confirm your appointment. If others are traveling with you please provide name(s) and DOBs.

Comments:
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