Stanford Family Practice
SFP Travel Advice Information

We provide travel advice and immunizations only to patients who have previously established care at Stanford Family Practice.

You may print this form and either FAX to your doctor at SFP at 650/725-7750 - or -
bring the form to your appointment.



Name: Email Address: Date:
Medical Record Number: Primary Care Physician: Date of Departure: Date of Return:
Is this an organized tour or on your own?
List Countries Visited and Duration of Visit:
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Year of Last Tetanus Shot:
Year of Last Oral Polio Vaccine
Year of Last MMR Vaccine
Have you completed the Hepatitis B Vaccine? Year Completed

Have you completed the Hepatitis A Vaccine? Year Completed

Year of Last Typhoid Vaccine
Year of Last Yellow Fever Vaccine?
Year of last Meningoccoccal Vaccine?
Current Medications: (name/dose/frequency)
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Do you have Medication Allergies?
If Yes, please list them:
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