Holiday vaccinations request form

Holiday vaccinations request form

Please complete this form and return to reception asap so that a 'Travel Risk Assessment' can be carried out prior to your appointment. Please give the surgery a ring a week later to book an appointment if needed. Ideally, you need to have the vacinations at least 2 weeks prior to your holiday. If you don't this will cause a risk to you not being fully immune. If you are late in booking your vaccinations, we will do our best to accommodate where possible, but please note that your lack of forethought is not our responsibility.

Itinery & purpose of travel

Medical history

WOMEN ONLY

FOR OFFICE USE ONLY