Travel questionnaire
Please complete the travel questionnaire as accurately as possible to assist the surgery in knowing which immunisations and injections you require
Complete the questionnaire at least 6 weeks before travel
You should call complete the questionnaire at least 6 weeks before your departure date and allow enough time for your nurse traveller's appointment. This is to ensure that the vaccinations have good time to take effect
The practice does not offer some vaccinations
The practice does not offer yellow fever vaccinations, rabies or japenese B encephalitis.

Please the following local travel centre: Boots, 137-139 High Rd, London N22 6BA
Antimalaria medication is NOT available as an NHS prescription
If you are traveling to a high risk area as per the website: https://www.fitfortravel.nhs.uk/destinations.aspx you may need anti-malaria medication. This is not available as an NHS prescription. If you need this please obtain from your local chemist
Your Details
Please include your latest personal details so that we can contact you if necessary
Your Full Name *
Your Date of Birth *
Please include your DOB in the form of DD/MM/YYYY i.e 01/01/1980
Your MOBILE number *
If we need to contact you to clarify your answers
Your EMAIL address *
If we need to contact you to clarify your answers
Travel questions
Date of DEPARTURE from the UK *
What date are you leaving the UK
MM
/
DD
/
YYYY
Date of RETURN back to the UK *
What date are you leaving the UK
MM
/
DD
/
YYYY
Which COUNTRY are you visiting? How LONG are you staying in each country (in DAYS)? *
Please describe you are countries visiting and length of stay i.e. KENYA - 5 days and INDIA - 14 days
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