Travel Vaccination Form

Please complete the form below to get more information about what travel immunisations you require. Ring the surgery on a Thursday after submission of this form, and the receptionist will inform you if you need to make an appointment.

Most vaccines are given at least 2 weeks before travel, and some more complicated regimes take longer. Please try to give us prior notice (preferably 6 weeks).

Your Details

Name*

Date of Birth*

Email Address *

Contact Number

Work Contact Number

Are you Pregnant?yes no

 

Destination(s) Town/Country	Date of Travel	Length of Stay

Accommodation Hotel
Self Catering
Relative/Friend
Camping/Backpacking
Other

Are you fit to travel? yes no

Do you have any allergies? yes no

Medical Conditions	Current Medication

Previous Vaccines	Date
Tetanus
Polio
Hep A Dose 1
Hep A Booster
Typhoid
Yellow Fever
Meningitis
Other

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Statement: To the best of my knowledge this information is correct.