Travel Vaccination Clinic Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Date of Birth Day Month Year Contact NumberAddress Street Address Address Line 2 City Postcode Travel DetailsDate of departure Day Month Year Total duration of trip (in days)Please enter a number from 0 to 99999.Which country will you visit? Which exact location or regions? City, rural areas, or both? City Rural areas Both The length of stay? If visiting more than one country, please answer the questions above per country. OptionalWhich modes of transport will you be using? Have you taken out travel insurance for this trip? Yes, sorted Not yet, but will do soon No, not needed Do you plan to travel abroad again in the future? Yes No Type of travel and purpose of trip Holiday Business trip Expatriate Volunteer work Healthcare worker Staying in hotel Cruise ship trip Safari Pilgrimage Backpacking None Please tick all that applyFurther informationPlease let us know if: You are not fit and well today. Any allergies including food, latex, medication Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before? Recent chemotherapy/radiotherapy/organ transplant? Are you or your Partner pregnant or planning a pregnancy? Please specifyAre you currently taking any medication that was not prescribed by the practice? Yes No Please supply information on any vaccines or malaria tablets taken in the past not prescribed/administered by our practice.Any additional information OptionalAre you happy with these answers? Yes No Travel Vaccination Prices
