Please complete the form below if you are travelling abroad. If you would prefer you can print out a form here and post it to us or drop it in at the surgery.
Please complete this form at least 4–6 weeks before travel.
It is your responsibility to phone the surgery approximately 1 week after completing the questionaire to confirm vaccines required and make appointment.
NB – There will be a charge for anti-malarials as they are not available on the NHS and there is a fee payable for some vaccines e.g. yellow fever.
About this form
Fields marked with an asterisk are compulsory.
By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy.
Also, by sending this form you are indicating your agreement that the surgery may contact you by email or telephone to discuss the information contained in this form.
If either of these points concerns you or you disagree in any way then you should use another method of notifying us of your change of contact details.
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.
Date of birth
Contact phone number (no spaces)
Date of departure
Country to be visited
Length of stay
If you are travelling to multiple places please use the space below to list all destinations.
Travelling to a remote area/away from medical help?
Type of trip
Are you travelling...
Are you staying in an area which is...
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
List any current or repeat medications
Do you have any allergies for example to eggs, antibiotics, nuts?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Do you or any close family members have epilepsy?
Do you have a history of mental illness including depression or anxiety?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Women only: Are you pregnant or planning pregnancy or breast feeding?
Have you ever had vaccinations/malaria tablets such as: Tetanus, Polio, Diptheria, Typhoid, Hepatitis A, Hepatitis B, Meningitis, Yellow Fever, Influenza, Rabies, Jap B Enceph, Tick Borne? If YES, please list below:
When did you have it?
I confirm the above answers to be correct to the best of my knowledge and request immunisation for my trip together with advice on anti-malarials if appropriate.
Some required Fields are empty Please check the highlighted fields.
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