Start Your Travel Health Intake | Ajax Durham Travel Clinic

Screening Questions

Please answer these questions first. Some situations require a direct phone consultation rather than the online intake.

I am travelling within 14 daysI am pregnant or immunocompromised (HIV, transplant, biologics, chemotherapy, high-dose steroids)This intake is for an infant under 6 months of ageI am a returning traveller with current symptoms

Patient Information

Full Name *

Date of Birth *

Email *

Phone *

I confirm I am a resident of Ontario *

Travel Details

Destination(s) *

Enter all countries you plan to visit, separated by commas

Travel Start Date *

Travel End Date *

Purpose of Travel *

Accommodation Type *

Planned Activities *

Medical History

Consent & Acknowledgment

I understand AI will assist with my intake and a physician will review and authenticate any recommendations before I receive them. *I understand my data is stored on Canadian-hosted infrastructure and used only for my care, per the Privacy Policy. *I am physically located in Ontario at the time of this submission. *