Travel Vaccination Request

Please complete the following form and send to the surgery/hand to a receptionist, at least 4 weeks before your planned travel date.

Please complete the following form and press Submit (fields marked with a * are mandatory, a telephone OR mobile number must be provided):












Countries to be visited - in order of visit. Please indicate places and approximate duration of stopovers, in days:






















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Will you be sleeping rough or camping?Are you taking steroids?Are you taking any regular medicines?Have your reacted badly to previous vaccines?Are you allergic to any antibiotics?Are you on any other treatment? (e.g. anti-cancer)Are your pregnant?Have you had a splenectomy?

Please also list any immunisations you have had over the last 10 years:












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