Chilwell Valley and Meadows Travel Form
Please note: you must be a registered patient at our practice in order to receive travel advice from us.
If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary
To help the travel nurses to assess your needs it is important that they receive the completed travel assessment form 8 WEEKS before your departure.
BY COMPLETING THIS FORM YOU ACCEPT THAT YOUR PERSONAL DATA AS ENTERED BELOW WILL BE SECURELY STORED ON GOOGLE'S SERVERS AND WILL ONLY BE ACCESSED BY PRACTICE STAFF FOR THE PROVISION OF YOUR HEALTHCARE. IF YOU ARE NOT HAPPY WITH THIS PLEASE RETURN TO THE PRACTICE WEBSITE AND DOWNLOAD A COPY OF THE FORM TO COMPLETE BY HAND AND GIVE TO RECEPTION.
Date of birth:
Daytime phone number:
Preferred method of contact:
If by phone what time is preferred:
Prefer not to say
For women only:
Are you currently pregnant or planning a pregnancy?
Are you currently breastfeeding?
Date of departure:
Please give details of the country(s) you are travelling to, including length of stay and areas to be visited:
Type of trip:
Holiday type: (Tick all that apply)
Health care worker
Friends or family home
With family / friend
In a group
Staying in area which is:
Please list any allergies, e.g. eggs, nuts or antibiotics:
Have you ever had a serious reaction to a vaccine given to you?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
We advise that you should have comprehensive travel insurance before travelling. Have you informed your insurance company about any past medical history?
Please write any further information you feel we should be aware of:
Have you ever had any of these vaccinations /tablets (Tick all that apply):
Japanese B Encephalitis
Tick Borne Encephalitis
I confirm that I have read the Travel Health Pro website regarding the countries I am visiting:
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