Travel the world.


A STAMARIL Center
John D. Wilson, M.D.
1200 Hilyard St., Ste. 560
Eugene, Oregon 97401 USA
541.343.6028
fax 541.485.7702
www.TravelClinicOregon.com

 

Please complete this information if you have not been seen by The Travel Clinic before, or if you are a prior patient planning a new trip.

Name:
Phone:
City:
Email:
Date Depart:
Duration:
Countries Visiting:
Names and birthdates of travelers:
Former Patient?
Referred By:
If you are a prior patient and have a brief question or statement, please leave it here:
 
 

 

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  John D. Wilson, M.D. 1999-2017; Last Update 8/17/2017