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Travel Vaccinations

Please complete the following form to request immunisation appropriate to your travel plans together with advice on anti-malarial drugs.

Failure to complete the form correctly and in full may delay your vaccination programme.

Appointment Details

Please provide in the format DD/MM/YYYY
HH:MM

2 Your Details

Please provide in the format dd/mm/yyyy

3 Your Travel Arrangements

Please provide in the format DD/MM/YYYY

4 Destination(s)

Please give details of which countries and areas you are visiting along with the dates of your stay.

Country 1


Country 2


Country 3


5 Previous Immunisations

Please state whether you have had the following immunisations, along with the date given.


6 Further Information

Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.

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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has 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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