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.
The form must be completed before your appointment.
The appointment with the practice nurse must be at least 6 weeks before you are due to travel.
Please state whether you have had the following immunisations, along with the date given.
Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.
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.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.