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Travel Vaccinations

Please complete the following form to request immunisation 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 NOTE: IF YOU ARE TRAVELLING IN LESS THAN 6 WEEKS, WE WILL BE UNABLE TO COMPLY WITH YOUR REQUEST. PLEASE BE VERY SPECIFIC WHEN SUPPLYING US WITH TRAVELLING INFORMATION. PLEASE SUPPLY US WITH THE NAME OF THE COUNTRY, THE REGION, AREA AND TOWN YOU ARE TRAVELLING TO.

You are strongly advised to visit www.fitfortravel.nhs.uk/ to obtain the latest travel information for the area you are visiting

1Your Details

Date Of Birth

2Your Travel Arrangements

3Country 1

4Country 2

if none, please write none

5Country 3

Dates of your stay, if more than one visit

6Previous immunisations

Please give details of any other vaccinations you have received

Current medications or conditions

Please give details

7For Office Use Only

Please do not complete this section. For internal use only

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.

Your Neighbourhood Professionals Anniesland Essential Dental Care Rettie Black and Lizars Central Psychology Scotland
© Neighbourhood Direct Ltd 2017
85 Milngavie Road, Bearsden, Glasgow, G61 2DN
  • Telephone 0141 212 0700
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Your Neighbourhood Professionals
Anniesland Essential Dental Care Rettie Black and Lizars Central Psychology Scotland
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