1250 East Green Street • Pasadena • CA • 91106
626 • 584 • 1200
Please do not access forms using a mobile device. Use your desktop or laptop device.
REGISTRATION FORMS - ALL TRAVELERS
DO NOT USE THIS FORM IF YOU ARE NOT TRAVELING
• You are a NEW PATIENT visiting our clinic for the first time.
• Patients returning after 1+ years, we need to update your files.
Please download the following forms below. Bring completed forms on day of appointment along with a list of vaccinations, medications and itinerary.
Allow 45 minutes for your visit with us. If this is a problem, we are happy to reschedule you when you have more time.
NEW AND RETURNING PATIENTS TRAVELING REGISTRATION FORMS- Download here
All new and returning travel patients complete this registration form and every 12 months when returning for a visit.
THIRD-PARTY CREDIT CARD AUTHORIZATION- Download here
Complete this form only if someone else (Third Party) is paying with their credit for your medical services, and the cardholder will not be with you.
MEDICARE WAIVER OF CONSENT- Download here
In compliance with Medicare requirements, we need to have you complete this form if you are Medicare eligible and/or 64 years or older.
TRAVEL INSURANCE- Follow this link
If you are seeking travel insurance for medical, emergency evacuation, trip delay and other travel benefits, following our link will allow you access our negotiated rates.
PAYMENT FOR MEDICAL SERVICES
We accept Debit Cards (no fees), Cash, VIsa, MasterCard, Discover and American Express. We do not accept personal or business checks. If another individual is paying for your visit, we need an advance authorization. See above consent form. Please call us for any payment questions.
We are currently not a member of any insurance plan or group at this time.We do provide you with an itemized statement of services which you may submit to your insurer for direct reimbursement.
"Why doesn't my insurance pay for this?"
Employer-paid medical insurance coverage will only cover approved services by your employer. Insurance companies administer what your employer has agreed in advance. You will need to check with your insurance administrator if there is a covered benefit(s), and if so, you will need to submit directly to your insurance company. Our clinic does not provide any insurance billing to your carrier.
PLEASE ARRIVE ON TIME FOR YOUR APPOINTMENT
We respect your time and and in order to see you as scheduled, please don’t be late. Late arrivals are not fair to other patients that have arrived on time for their appointment. In fairness to these patients, we will need to reschedule you for a different time and date. Remember, Los Angeles traffic can be unpredictable so please allow plenty of time to get here.
DON’T BE A NO SHOW.
Provide us with at least a courtesy call 48 hours in advance to cancel or reschedule so that we may allocate your appointment time to another fellow traveler.
1250 East Green Street in Pasadena.
Use your Apple or Google Map App for GPS direction by typing "Healthy Traveler Pasadena."
Non-metered street parking is available on both sides of East Green Street as well as north and south on Chester Avenue.
Questions? text us back or call our clinic at 626-584-1200.
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