Pre-Travel Questionnaire

Please complete this form (one per patient travelling) and return it to the surgery at least 6 weeks prior to travel.

We would advise you do not complete this form if your date of travel is within 6 weeks, as it is unlikely we will be able to offer appointments for travel vaccinations within this time frame.

If your date of travel is within 6 weeks we would suggest you contact a private travel clinic for your travel vaccination assessment/advice and vaccinations. Details of local private travel clinics are available from our reception team.

Please telephone the surgery on 01525 300898 seven days after submitting this form to enquire whether you need any vaccinations and, if appropriate, to book the necessary appointments.

Not all vaccinations are available on the NHS and may be chargeable, and full payment is required at the time of vaccination.

For more information on travel vaccinations, please view our Travel Immunisations page.

Pre-Travel Questionnaire

Pre-Travel Questionnaire

Travel Details

Please use date format: DD/MM/YYYY

Personal Medical History

Women only.

Vaccination History

I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.