Netherfield Medical Centre Travel Vaccination Form
- If you are travelling within the next 8 WEEKS
- Or if in the 8 WEEKS you are going on an adventure/ backpacking holiday of more than 1 month’s duration
we will be unable to offer you your injections
- Travel Doc Tel 0800 583 3331
- Or Walk-in Centre 8440212
You can copy this form and send to the surgery.
Name Date of Birth
Easiest contact Telephone number
Male( ) Female ( )
Dates of Trip
Date of Departure
Return Date or overall length
Itinerary and purpose of visit
Length of Stay
Away from medical help at destination ? how far
Country to be visited
Type of trip
With family /friends
In a group
Staying in area which is
Personal Medical History Yes No
Do you have any recent past medical history of note (including diabetes, heart or lung) conditions ?
Do you have any allergies eg eggs, antibiotics nuts?
Have you had a serious reaction to a vaccine given to you before?
Does an injection make you feel faint ?
Do you or any of your close family have epilepsy ?
Do you have any history of mental illness including depression or anxiety ?
Have you recently undergone radiotherapy, chemotherapy, steroid treatment?
Women only Are you pregnant or planning a pregnancy or breast feeding?
Please contact the Surgery 3 days after handing in the completed form,
when you will be advised whether or not you require any vaccinations.
If you do ,you will then need to book an appointment.