Mission Trip Clinic Agreement

  1. Education. Passport Health will come on site to educate the mission trip participants (and their parents, if applicable) about food and water precautions, insect borne illnesses, diarrhea prophylaxis, current issues relating to the destination, and vaccines and prescriptions advised. This generally takes about 25 minutes, depending on how many questions listeners have.
  2. Immunization. Passport Health hascertified nurses who will administer the recommended immunizations. Those receiving vaccines are strongly encouraged to have paperwork filled out prior to the clinicso things run as efficiently as possible.
  3. Equipment and Disposal. Passport Health will supply all necessary equipment including disposable syringes, alcohol swabs, gloves, gauze and band-aids.
  4. Documentation. Immunizations will be documented on the patient’s immunization card (or an official Yellow Card can be distributed if needed) and documentation of the immunizations will be kept on file for three years.
  5. Fees. The normal fee of $50 per person for an office visit is waived for groups of 8 or more where we go on-site. There is a $10 per person prescription fee. Any person coming to the office for the initial consultation must pay the office visit fee. Some vaccines require a series of shots to be effective; prices are per dose: The below prices are significantly discounted from our regular prices.

Hepatitis A (adult/child) $75/$55Hepatitis B (adult/child) $75/$55

Twinrix $140 Influenza $20

IXIARO $230 Meningococcal $125

MMR $75 Pneumococcal $55

Polio $55 Rabies $250Varicella $110

Tetanus/Diphtheria $40Tet/Diphtheria/Pertussis $60

Typhoid $70Yellow Fever $105

  1. Payment is due when services are rendered. We accept cash, check or credit cards (American Express, Visa and Master Card).
  2. Coordinator. The Mission Group should have a coordinator available to assist with passing out forms and to assist with any technical issues that may arise. We will need two tables and four chairs during vaccine administration.

Date and Time of Mission Trip Clinic:______

Destination(s) and dates of travel______

(Please use a separate sheet of paper if needed)

______

Group Representative (printed) Signature

Please fax this signed report to Passport Health at 1-866-272-0960.

The Vaccine People

4011 West Plano Parkway, Suite 106 Plano, TX 75093

Tel: (469) 241-1954 Fax (866) 272-0960 Toll Free: 1-888-499-PASS (7277)

Locations in Dallas, Plano, Grapevine, Fort Worth and Lewisville

Also: Alabama,Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Missouri, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington, Washington, D.C., West Virginia, Wisconsin