Travel Form

If you are travelling abroad and require advice and/or vaccinations please click here to download the travel vaccination and enquiry form which you should complete and hand in to reception. Once the form has been completed in full and returned to us you can make an appointment with the nurse. Alternatively it can be completed online below. The form should be submitted and the appointment arranged 6-8 weeks before you travel to ensure that any course of vaccinations required can be appropriately completed and be considered effective.

Please click here for more details about current charges to patients for travel vaccinations or certificates.   All payments are to be made by cash or cheque only.

Please note that if completing this form you must read the additional information and guidance supplied HERE and also make an appointment with the nurse for your travel consultation and any vaccinations if you wish to proceed.  Travel vaccination charges where these apply will need to be paid on the first visit and for any courses these are non-refundable. 

Please note there is currently a national shortage of Hepatitis A&B vaccine so the practice cannot provide these at the present time.  The nurse will advise you if these vaccines are available alternatively you can consult with a local private travel clinic.    

1Travel Form

Travel risk assessment and enquiry form – to be completed by the traveller 6-8 weeks prior to travel and prior to an appointment being made with the nurse.

2Medical History

Please provide details about your personal medical history below:

3Women Only

4Vaccinations

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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Shotfield, Wallington, Surrey, SM6 0HY
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Save time and nominate your local pharmacy. Your Neighbourhood Professionals Counselling: why wait for a NHS appointment? Contact a private counsellor today Lenore Dunmore Counselling
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