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.
Please give details of which countries and areas you are visiting along with the dates of your stay.
Please state whether you have had the following immunisations, along with the date given.
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.
I consent to my information being used for the purposes described above and wish to submit this online form to
Birchills Health Centre
23 - 37 Old Birchills, Birchills, Walsall, WS2 8QH.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.