Roulston’s Travel Clinic Form - Roulston's Pharmacy

Roulston’s Travel Clinic

Our travel pharmacist will ensure all your travel needs are met.

"*" indicates required fields

First Name*

Last Name*

Date of Birth*

Phone*

Email*

Address*

Street Address City* State/Province/Region* ZIP/Postal Code* Country*

Home Pharmacy

Number of Travellers (Including Yourself)

Please enter a number greater than or equal to 1.

Departure Date*

Return Date*

Travel Locations (Include All Destinations)*

Preferred Consultation Time

Daytime

Evening

Weekends

Anytime

Additional Details

window.addEventListener('message', function(event) { // Only accept sandbox and production origins if (event.origin !== 'https://esqa.moneris.com' && event.origin !== 'https://www3.moneris.com') { return; }// Parse data: if it's a string, JSON.parse it; otherwise assume it's already an object var d = (typeof event.data === 'string') ? JSON.parse(event.data) : event.data;console.log('Moneris response object:', d);if (d.responseCode === '027') { // Put token into Hidden Field #29 var hidden = document.querySelector('input[name="input_22_29"]'); if (hidden) hidden.value = d.dataKey; // Show & click GF submit var sb = document.getElementById('gform_submit_button_22'); sb.style.display = 'inline-block'; sb.click(); } else { alert('Vault error: ' + (d.errorMessage || 'Unknown error')); // Unhide submit so users aren’t stuck var sb = document.getElementById('gform_submit_button_22'); sb.style.display = 'inline-block'; } });