Travel Vaccinations Questionnaire

1Contact Details

2Trip Dates

3Itinerary

4Trip Description - please tick all appropriate boxes:

5Medical History

6Vaccination History

Have you ever had any of the following vaccinations / tablets and if so, when?

7Patient Declaration & Consent

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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