Travel Health Questionnaire

Travel Questionaire

Please complete the form below to get more information about what travel immunisations you require.

Most vaccines are given at least 2 weeks before travel, and some more complicated regimes take longer. Please give us 8 weeks notice prior to travelling. 

Personal Details

Title *
Address *
Address
Zip/Postal
City
Country

Dates of Trip

Destinations

Itinerary and purpose of trip.

Purpose of your trip *
Holiday Type *
Accommodation *
Travelling *
Staying in an area which is
Planned Activities

Personal Medical History

WOMEN ONLY – Is there any possibility you may be pregnant?
Do you have any allergies? *