Travel Health Form

Non-urgent advice: Please Note

If you do not submit your questionnaire at least 8 weeks before your travel date, we will be unable to see you; however we may be able to recommend other, local travel clinics that may be able to accommodate you.

If you require any vaccinations relating to foreign travel you will need to complete a Travel Health Questionnaire. You must submit the questionnaire at least 8 weeks before the date of travel, but we advise you do this as early as possible. We insist on at least 8 weeks’ notice because;

– The nursing team need sufficient time to safely check your region of travel; sometimes different regions of the same country have different advice/vaccination requirements.

– We may have to order some vaccinations in, especially less common ones.

– You may require more than one dose of a vaccination, spread over several weeks.

– If there is a group of people travelling together, each patient will need separate appointments for their vaccinations, this can be problematic to schedule.

The Health Questionnaire allows the Nursing team to assess your health needs, it is very important you include the region of the country you are visiting as this can impact on the advice or vaccinations required. You can complete the questionnaire online, via the link below or collect a printed copy at Main Reception.

Once you have submitted your questionnaire the nurse will check the information and then the surgery will contact you to arrange a suitable appointment.

Please note before completing the questionnaire

– If you do not submit your questionnaire at least 8 weeks before your travel date, we will be unable to see you; however we may be able to recommend other, local travel clinics that may be able to accommodate you.

– To avoid unnecessary delays please include your region of travel as well as Country as this may alter what vaccinations are required.

To help us offer the appropriate advice, please fill out the online form below before coming to see the nurse.

Personal Details

Name
DD slash MM slash YYYY
Address

Trip Dates

Itinerary

PLEASE MAKE SURE YOU INCLUDE REGION OF TRAVEL AS WELL AS COUNTRY
If you are going on a cruise only tell us about the destinations that you are in port for more than 24 hours. We do not need a list of your one day excursions. If you are staying on land overnight anywhere we will also require this information.
Location Type:

Trip Description

Please tick all appropriate boxes:
Purpose of Trip:
Type of Trip:
Accommodation:
Travelling:
Activity Type:

Personal Medical History

Please tick any of the following which apply

Vaccination History

Have you ever had any of the following vaccinations / tablets and if yes please tick the box and provide the date.

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.