Travel Vaccinations

Please only complete this form if you are a registered patient at Woodbrook Medical Centre

Travel Vaccinations

Name:

Date of Birth:

Contact number:

When do you leave?

When do you return?

Please tell us all of the countries you will be visiting or staying in and include the nearest city

What is the nature of your travel?

Accommodation type:

Are you on any prescribed medication?

If you answered yes above please tell us what prescribed medication you are currently taking

Are you taking any over the counter medication?

If you answered yes above please tell us what over the counter medication you are currently taking

Are you on any antibiotics or steroids?

If you answered yes above please tell us what antibiotics or steroids you are currently taking

Are you immuno-suppressed? i.e. spleen removed.

For female patients - Are you Pregnant?

Any Previous Immunisations?

Have you had any reactions to previous vaccines?

If you answered yes to having had a reaction to a previous vaccine, please tell us what happened?

Do you hold a yellow fever certificate?

WE ONLY PROVIDE TRAVEL VACCINATIONS FOR REGISTERED PATIENTS.

TRAVEL FORMS MUST BE SUBMITTED AT LEAST 6 WEEKS BEFORE YOUR TRAVEL DATE OR YOU MAY HAVE TO ATTEND A PRIVATE CLINIC.

PLEASE NOTE IT IS YOUR RESPONSIBILITY TO ADHERE TO ANY RECOMMENDATIONS GIVEN BY YOUR NURSE, GP OR TRAVEL AGENT ESPECIALLY ANY CHANGES MADE AT SHORT NOTICE.

I CONFIRM THAT THE ABOVE ANSWERS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND I CONSENT TO ANY INJECTIONS I MAY REQUIRE

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This information is retained for up to 28 days.

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