Travel Health Questionnaire

1Personal Details

2Trip Dates

3Itinerary

4Trip Description - please tick all appropriate boxes:

5Personal Medical History

6Vaccination History

Have you ever had any of the following vaccinations / tablets and if so, when?

7Patient Declaration & Consent

I have given full and accurate information regarding my medical and vaccination history and travel plans. I have been advised to have the vaccines and other items indicated with a YES tick in the treatment and advice schedule overleaf.

I understand the health risk and advice given and consent to vaccination and the payment of fees for non-NHS vaccines

Or (delete as applicable)

I understand the health risks and advice given and consent to vaccination and the payment of fees for non-NHS vaccines except for ………………………………………

I understand and accept the risk of disease in unvaccinated.

Type your name here

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 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.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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Fields Park Drive, Alcester Warks, Warks, B49 6QR
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Your Neighbourhood Professionals. Just a Click Away!
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