Download and print this two-page form if you are a new patient to Capitol Travel Medicine. If you are unable to do this, we will be happy to fax or mail you a copy. To save time, bring the completed form to your appointment along with any previous vaccination records.
Patient Information Form (Adobe PDF Format - 2 pages)
If you are an existing patient and have completed an updated patient information form for a prescription refill, please fax it to 703.351.1445.