PC-BC Health Department

Bureau & Putnam County Health Department
	Princeton Office 526 Bureau Valley Parkway Princeton, IL 61356 Phone: 815-872-5091 Fax: 815-872-5092		Hennepin Office 220 East High Street Suite 102 Hennepin, Illinois 61327 Phone: 815-925-7326 Fax: 815-925-7001

Office Hours: Monday thru Friday 8:00-12:00 and 1:00- 4:00 p.m.

Foreign Travel Consultation Record

Contact:
Bureau Putnam County Health Department
Pat Lebahn, RN BSN
815-872-5091, ext 221
plebahn@bchealthdepartment.org

Traveler First Name:

Traveler Last Name:

Date of Request:

Address:

City:

State:

Zip:

E-mail:

Day Telephone:

Evening Telephone:

Fax:

Best Method of Contact:

Names of Travelers

Age

Special Medical History/Medicines

Itinerary

List of COUNTRIES in order of visit:	Date of Departure/Duration of Stay
US to:
US to:
US to:
US to:
US to:
US to:

Purpose of Travel: (pleasure, business, missionary, etc.)