Travel Vaccinations

Hugglescote Surgery are able to offer travel vaccinations to patients registered at the surgery. Please complete this form so that the nurse team can book you an appointment.

Please note that you should complete this at least 8 weeks prior to the date of travel. If you can’t give this much notice, please seek an alternative provider such as your local pharmacy.

Travel Vaccinations

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Your Details

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Phone Number(Required)

Trip Details

Please provide information about your trip in the sections below.

Date of Departure(Required)

DD slash MM slash YYYY

Return Date(Required)

DD slash MM slash YYYY

Duration of Trip

Location(s)(Required)

Please list all countries that you will be visiting. You can add a new row by clicking on the + icon at the end of the row.

Country to be visited

Exact location or region

City or Rural

Length of Stay

 

Add Remove

Travel Insurance(Required)

Have you taken out travel insurance for this trip?

Yes

No

Future Trips(Required)

Do you plan to travel abroad again in the future?

Yes

No

Type of Travel and Purpose of Trip(Required)

Please select all that apply

Holiday

Business Trip

Expatriate

Volunteer Work

Healthcare Worker

Staying in Hotel

Cruise

Safari

Pilgrimage

Medical Tourism

Backpacking

Camping / Hostels

Adventure

Diving

Visiting Friends / Family

Medical History

Please provide details of your medical history. Further information can be included at the bottom of this section in the 'More Information' box.

Medical Details(Required)

* Please provide details in the box below.

	Yes	No
Are you fit and well today?
Do you have any allergies? *
Ever had a severe reaction to a vaccine? *
Have you ever fainted during a vaccination?
Have you ever had a surgical operation? *
Have you recently undergone chemotherapy or radiotherapy? *
Have you recently received an organ transplant? *

Conditions(Required)

Have you been diagnosed with any of the following:

	Yes	No
Anaemia
Bleeding / clotting disorders (including DVT)
Heart disease (eg angina, high blood pressure)
Diabetes
Epilepsy / seizures
Gastrointestinal (stomach) complaints
Liver and / or kidney problems

More Information

Please use this box to provide any further details of conditions listed above.

Medical Information continued

What travel vaccinations caused you a reaction?(Required)

Consent

Please note it is your responsibility to adhere to any recommendations given by your nurse, GP or Travel Agent especially any made at short notice.

Signature(Required)

I confirm that the answers I have given are true to the best of my knowledge and I consent to any injections I may require. (Parent / guardian to sign if under 16 years old)

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Date

DD slash MM slash YYYY

Post Custom Field

Phone

This field is for validation purposes and should be left unchanged.