Travel Vaccination Form Travel Questionnaire Please complete the form below to provide us with more information about your trip and the vaccinations that you may require. Once you have completed this form, please book an appointment with our nurse at least 6 weeks before you are due to travel. She will go through this prior to your appointment so that she can give the relevant vaccinations and travel advice. Most vaccines are given at least a few weeks before travel, and some more complicated regimes take longer. Please be aware that we may not be able to accommodate vaccinations unless you are able to book an appointment at least 6 weeks before you travel.Title Mr Mrs Miss Ms Mx Dr Other Full Name Date of Birth Day Month Year Address Street Address Address Line 2 City Postcode Contact NumberEmail Enter Email Confirm Email Is there any possibility you may be pregnant? Yes No Destination(s) and Travel DetailsTotal duration of trip (in days)UK Departure Date Day Month Year Is the departure date within the next 2 months? Yes No As your departure date is within the next 2 months, we may not be able to offer an appointment at least 6 weeks before you travel. Please continue to complete this form, submit it, and book an appointment as soon as possible. The nurse will check the form and may still be able to offer some vaccinations and travel advice, but please be aware that we may not be able to and would need to cancel the appointment in some circumstances.First Country being visited Specific Area(s) of first country Rural or Urban? Length of stay Second Country being visited Optional Specific Area(s) of second country Optional Rural or Urban? Optional Length of Stay Optional Third Country being visited Optional Specific Area(s) of third country Optional Rural or Urban? Optional Length of Stay Optional Any additional countries/areas to be visited (include length of stay) Optional Mode(s) of Transport used (To/From destinations and within areas) Holiday type Package Self organised Backpacking Camping Trekking Cruise Ship Other Accommodation Hotel Hostel House/Apartment Chalet Caravan/Campervan Tent Open Air Purpose of your trip Holiday Business Expatriate Volunteer Worker Safari Pilgrimage Cruise Healthcare Worker Medical Tourism Backpacking Have you taken out insurance for this trip? Yes No Will you have access to clean drinking water? Yes No Will you have access to emergency medical care? Yes No Additional Relevant Information Optional