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Pharmacie Labib Fraih and Manal Karzon SENC
Travel Consultation and Vaccination

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Travel consultation and vaccination appointment in Montreal

TRAVEL CONSULTATION REQUEST

consultation fee of $50 per person

First name*

Name*

E-mail*

Address*

Phone*

Date of birth*

Day

Month

Year

Have you ever experienced significant adverse reactions following a vaccination?*

Yes

No

Are you pregnant or breastfeeding?*

Yes

No

Are you vaccinated against hepatitis A?*

Yes

No

Are you vaccinated against hepatitis B?*

Yes

No

Are you vaccinated against yellow fever?*

Yes

No

Have you been vaccinated against tetanus in the last 10 years?*

Yes

No

Do you have an immune system disorder (e.g. lymphoma, leukemia, HIV/AIDS, taking certain medications such as chemotherapy or a biological agent)?*

Yes

No

Known health problems

List of medications taken on a regular basis

Departure date for the trip*

Countries and cities visited*

Initials*

I declare that I have read the information located in the Remote Pharmaceutical Services section and I consent to use the technology to receive my pharmaceutical services remotely.

Please fill out and submit this form. We will contact you as soon as possible to schedule an appointment. Your private drug insurance may cover part of the cost of the prescribed vaccines. If you would like us to add your drug insurance to your file, please send us a photo of your drug insurance card to pharmaciepetitepatrie@gmail.com.

This page is for scheduling a travel consultation. A travel consultation allows us to assess your needs, prescribe and administer travel vaccines based on your destination and any previous vaccinations you have received. During the consultation, we will also prepare medications for traveler's diarrhea, malaria prophylaxis, and altitude sickness prophylaxis when indicated, and advise you on a travel kit if desired.

For yellow fever vaccination only, with submission of the yellow fever vaccination certificate, please complete the following form: www.vaccinationvoyage.ca/vaccinfievrejaune

937 St-Zotique East, Montreal H2S 1M9
514 370-2626
pharmaciepetitepatrie@gmail.com

Labib Fraih Pharmacy and
Manal Karzon SENC

Pharmacists are solely responsible for the practice of pharmacy.

© 2025 Fraih and Karzon Pharmacy

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