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Travel Consultation Form

Please complete your travel consultation form as soon as possible once you have made your appointment.

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Birthday
Day
Month
Year
Type of Trip
Tourism
Business
Visiting family/friends
Volunteering
Other
Holiday Type
Accommodation
Travelling
Staying in Area
Do you have any recent or past medical history of note (including diabetes, heart or lung conditions)?
Yes
No
Do you have any allergies e.g. nuts, eggs, antibiotics etc.?
Yes
No
Have you ever had a serious reaction to a vaccine given to you before?
Yes
No
Does having an injection make you feel faint?
Yes
No
Are you pregnant, trying to conceive or breastfeeding?
Yes
No
Are you currently taking medication or do you have an illness that will suppress your immune system?
Yes
No
Have you ever had any of the following vaccines? If yes, please state date in box below.

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement​ to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

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