If you are traveling with YouthLinc, please fill out the form below. When you’ve filled out the form, please click on the button that says “Submit”.

Please call your insurance company ahead of time to find out if they cover immunizations. If you have insurance, we must bill vaccinations to your insurance company. If you do not have insurance, payment for the vaccines will be due at the end of your appointment.

If you have any questions, please call the Travel Clinic at 801-581-2898.

Patient Information ("Patient" is the individual attending YouthLinc)

Patient Pharmacy Information (for prescription requests)

Emergency Contact Information

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Guarantor Information (Patient’s Legal Guardian)

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Insurance Information

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Online Pre-Travel Questionnaire Confirmation Code

All YouthLinc participants must fill out our online pre-travel questionnaire. We must know if the participant is on any medications. Once the form is completed it will generate a number and that number needs to be entered below. Please keep your confirmation number for your own records. To access the online pre-travel questionnaire, go to https://www.travelmdus.org/ and click on the “U. Utah Hospital” (the last link on the bottom of the page). Follow the instructions on the Global TravEpi Network homepage, fill out the questionnaire, and record your confirmation number given after you complete your questionnaire.

Or Call 801-581-2898