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

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

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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Your Neighbourhood Professionals. Just a Click Away! Alcester Home Care Agency - Your Home, Your Care
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