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Travel Clinic Pre-Consultation Form

Travel Clinic

Pre-Consultation

Please fill in this form before your appointment

Once we receive your Pre-Consultation form our pharmacist can review your details and assess which Vaccinations and/or Malaria treatments you will need for your Travel. Please do not hesitate to contact us if you have any queries

Full Name*

Address*

Date of Birth

My Telephone No.*

Email Adress*

Date of Departure

Overall Length of Trip

Country to be visited and length of stay

Purpose of Travel - Check which applies

Adventure. Diving Long-term ( backpacker/expatriate/volunteer/work ) Remote destination Visiting Friends/Relatives Cruise Healthcare worker Medical Access? Medical tourism Natural Disaters Pilgrimage Trek Other Please mention

Other

Vaccination History - Give dates of previous vaccines-Diphtheria

Meningitis

Tetanus

Hepatitis A

Hepatitis B

Japanese Encephalitis

Polio

Rabies

Typhoid

Personal Mediacl History - Check if any apply to you

Allergies Anaemia Bleeding/clotting disorders Diabetes Disability Epilepsy/seizures Gastrointestinal ( stomach ) complaints Heart disease ( eg angina/high blood pressure ) HIV/AIDS Immune system condition Kidney problems liver problems Neurological (nervous system ) illness Respiratory disease Rheumatology conditions Spleen problems

Any other conditions

Are you pregnant?*

I confirm that the information provided is accurate and I consent to the secure processing of my personal and medical information in accordance with the Privacy Policy

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Monday - Friday	9:00 AM — 7:00 PM
Saturday	9:00 AM — 5:00 PM
Sunday	11:00 AM — 3:00 PM
2 Apr, 5 Apr, 3 May, 31 May	Closed

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