Please fill out the following form as completely as possible and then press the submit button at the bottom.  (Up to 3 family members)

  First name                  Last name

    M   F   Date of birth

    M   F   Date of birth

    M   F   Date of birth

Address  

City      Prov.           Postal code

Phone      E-mail address 

   submit number by phone later visa  mastercard  # exp

      Do you have any of the following health problems CHECK ONLY IF THE ANSWER IS YES

Yes Recent cancer treatment (chemotherapy or radiation), Organ transplant, HIV or AIDS, Oral steroid use, (if so your immune system may be suppressed and use of live vaccines may be contra-indicated)

Yes Egg allergy        Yes sulfa allergy         Yes Tetracycline allergy

Yes   A history of depression, anxiety attacks, seizures or epilepsy or any other neurological or mental problems ( if so use of some anti-malarial drugs may be contra-indicated)

Yes A cardiac arrhythmia (irregular heart beat)   ( if so use of some anti-malarial drugs may be contra-indicated)

Yes Have you ever had hepatitis or jaundice

Yes Are you pregnant

If you have any other medical problems which may be relevant please type them in the following text box;

 

Please Choose the type of travel applicable to your trip 

   Affluent Tourism ( hotels in urban or resort areas, hostels, with some day time travel to rural areas but not overnight)

   Business or Executive Travel

   Rural Travel (overnight exposure in villages, farms, small towns, camping or on a safari)

   Education (academic work teaching or studying)

   Working (if any of the following please check)    medical    Missionary  Airline employee  Veterinarian or animal handler

   Staying with relatives or friends (locals homes)

   Cruise

What is your departure date

What is your return date      

Please list IN ORDER the countries you plan to visit,  what month you will be there,  and how many days you will stay in each

 Country 1   starting month   number of days stay

 Country 2   starting month   number of days stay

 Country 3   starting month   number of days stay

 Country 4   starting month   number of days stay

 Country 5   starting month   number of days stay

 Country 6   starting month   number of days stay

If you are travelling to more countries, or have any other specific questions or concerns you wish to mention now please enter them in this text box.

What time is best for a telephone consultation? (we will call to set up an approximate time) Please note that there is a higher fee for weekend consultations. You can choose more than one option.

Wednesday business hours ($35 per person)

Weekday evening, after 7PM ($35 per person)

Weekend  ($45per person)

When you have completed the form please press Submit.   (Reset will clear the form if you wish to submit another trip)