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Travel Consultation Form

Please complete the travel health form for each person attending the consultation for us to plan your appointment timing

Are you a student?
Have you had a consultation about this trip in another clinic?

Please list all countries you plan to visit and duration of stay:

Type of Trip (tick all that apply) Required
Holiday Type (tick all that apply) Required
Activity Type Required
Accommodation (tick all that apply) Required
Medical conditions: do you have past or recent medical or surgical history of note (e.g. heart, respiratory, kidney, neurological, mental health, skin etc)
Medications: are you taking regular prescribed or over the counter medications?
Allergy to medications: do you have any medication allergies, including to antibiotics?
Other allergies: do you have any of the following allergies?
If yes, tick all that apply:
Immunosuppression: are you immunosuppressed, for any of the following reasons: (tick all that apply) Required
Vaccine reactions: Have you ever had a serious reaction to a vaccine given to you before?
Vaccine reactions: Does having an injection make you feel faint?
Pregnancy and breastfeeding: are you pregnant, planning to conceive while travelling or within 3 months of your return, or breastfeeding?
Travel vaccine history: have you ever had any of the following vaccines: Required

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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