Travel Vaccine Request Form

THIS FORM MUST BE COMPLETED AT LEAST 6 WEEKS PRIOR TO YOUR ESTIMATED TRAVEL DATE
Personal Details:

Date of Birth:

Address:

MaleFemale


Dates of Trip:
Departure Return (if known)
Detail about destination(s):
Country and location to be visited (please detail if more than one)Length of stay at each locationAway from medical help at destination, if so, how remote? Do you plan to travel abroad again in the near future? YESNO
Please tick as appropriate below the best that describes your trip:
Visiting Area:
UrbanRural
Accommodation:
HotelRelatives/Family homeCamping
Travelling:
AloneWith family/friendIn a group
Other:
Cruise ShipBackpackingTrekking
Personal Medical History:
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
List any current or repeat medications:
Do you have any allergies? For example; eggs, antibiotics, nuts or latex?
Have you ever had a serious reaction to a vaccine given to you before?





Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
Please write below any further information which may be relevant
Vaccination History:
Have you ever had any of the following vaccinations/malaria tablets and if so, when?
TetanusPolioDiptheriaTyphoidHepatitis AHepatitis BMeningitisYellow FeverInfluenzaRabiesJab B EncephTick BorneNot sure
Details of above
NB: PLEASE ALLOW TWO WEEKS FOR THE NURSE TO PROCESS THIS FORM BEFORE YOU CONTACT THE SURGERY TO CHECK IF ANY VACCINATIONS ARE REQUIRED