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”.

All YouthLinc participants must fill out our online pre-travel questionnaireIt will generate a code when completed and that code needs to be entered at the bottom of this form.

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.

Please also be sure to provide the information for the insurance subscriber (primary policy holder).

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

Patient Information ("Patient" is individual attending YouthLinc)

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

Or Call 801-581-2898