Travel Questionnaire

Once you have completed the form below please contact the surgery to make your appointment.

Please note there is a charge for several of the injections, please bring cash or cheque for your appointment.

Personal Details
Dates of Trip
Itinerary and purpose of visit:
Please check the boxes below to best describe your trip
Personal Medical History

(if not applicable please leave empty)

Vaccination History

For discussion when risk assesment is performed within your appointment: I have no reason to think that I might be pregnant. I have recieved information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questi

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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