Travel Vaccinations

Please complete the following form to request vaccinations 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.

Please be aware that we require a minimum of 6 weeks prior to your travel date to allow for the correct efficacy. If you are within this window you will  need to go to a Travel vaccine centre for advice and any vaccines. The nearest centres are Lincoln and Nottingham.

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Date of Birth: Required
Home Address: Required
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What date are you leaving the UK? Required
Is the trip for holiday or work? Required
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Destinations

Please give details of which countries and areas you are visiting, 

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Please give the date you arrive in the country: Required
Please give date you leave the country: Required
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Please give the date you arrive in the country:
Please give date you leave the country:
Please give the date you arrive in the country:
Please give date you leave the country:
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Previous Immunisations

Please state whether you have had the following immunisations.

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Further Information

Have you had any antibiotic treatment in the last 8 weeks? Required
Have you suffered from depression or any other psychiatric illness?: Required

Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or psychiatric illness.

Do you have epilepsy?: Required
Do you have medical problems requiring regular medication or check ups?: Required
Have you taken any steroids, or had immunosuppressive therapy e.g. chemotherapy, in the last 3 months? Required
Are you allergic to any medicines?: Required
Have you ever reacted badly to any vaccine?: Required
Are you pregnant or planning a pregnancy in the next 6 months?: Required

Privacy Protection

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.

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