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Travel Consultation Form

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

Type of Trip
Holiday Type
Staying in Area
Do you have any recent or past medical history of note (including diabetes, heart or lung conditions)?
Do you have any allergies e.g. nuts, eggs, antibiotics etc.?
Have you ever had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Are you pregnant, trying to conceive or breastfeeding?
Are you currently taking medication or do you have an illness that will suppress your immune system?
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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