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

Appointment datePlease provide in the format DD/MM/YYYY

Appointment timeHH:MM

Your Details

Title

First Name(s)

Surname

Home Address

Postcode

Home Phone Number

Mobile Phone Number

Work Phone Number

Date of BirthPlease provide in the format dd/mm/yyyy

Your Travel Arrangements

What date are you leaving the UK?Please provide in the format DD/MM/YYYY

Is the trip holiday or work?

Destinations

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

Country 1

Country 1 Name

Which area are you staying in in country 1? (Please be exact)

Please give dates of your stay in country 1

Please give details of your accommodation in country 1 (hotel, private house, camping etc)

Country 2

Country 2 Name

Which area are you staying in in country 2? (Please be exact)

Please give dates of your stay in country 2

Please give details of your accommodation in country 2 (hotel, private house, camping etc)

Country 3

Country 3 Name

Which area are you staying in in country 3? (Please be exact)

Please give dates of your stay in country 3

Please give details of your accommodation in country 3 (hotel, private house, camping etc)

Will you be visiting more than three countries?

Are you stopping elsewhere en-route?

Previous Immunisations

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

Tetanus

Have you ever had a tetanus immunisation?

Typhoid

Have you ever had a typhoid immunisation?

Cholera

Have you ever had a cholera immunisation?

Rabies

Have you ever had a rabies immunisation?

Hepatitis A

Have you ever had a hepatitis A immunisation?

Polio

Have you ever had a polio immunisation?

Meningitis

Have you ever had a meningitis immunisation?

Yellow Fever

Have you ever had a yellow fever immunisation?

Hepatitis B

Have you ever had a hepatitis B immunisation?

Diphtheria

Have you ever had a diptheria immunisation?

Please give details of any other vaccinations you have received

Further Information

Have you had any antibiotic treatment in the last 8 weeks?

Have you suffered from depression or any other psychiatric illness?Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.

Do you have epilepsy?

Do you have medical problems requiring regular medication or check ups?

Have you taken any steroids or had immunosuppressive therapy e.g. chemotherapy in the last 3 months?

Are you allergic to any medicines?

Have you ever reacted badly to any vaccine?

Are you pregnant or planning a pregnancy in the next 6 months?

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.

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.

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