Travel Form

In order for us to determine the vaccinations you will require for your travels please fill out the below form for our team to then contact you with further information.

Please read this statement carefully as you will be consenting to treatment.

I understand that I am opting for an elective treatment of vaccination

I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, social distancing is recommended. This is not entirely possible with my proposed treatment; however, I am satisfied that safety measures are in place (see website for details) to minimise risk as much as possible, and patient contact will be kept to an absolute minimum in line with medical need.

I understand the Management and Clinical Staff are closely monitoring the COVID-19 situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19 (see website for full details). However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment, and I give my express permission to proceed.  

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I understand that COVID-19 can cause additional health risks, some of which may not currently be known at this time, in addition to those risks associated with the treatment.

I have been given the option to defer my treatment to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment.

I confirm that I am not presenting with any of the following symptoms of COVOID-19 listed below:

• Fever
• Shortness of Breath
• Loss of Sense of Taste or Smell
• Dry Cough
• Runny Nose
• Sore Throat

By clicking this box I agree to the terms outlined above and I understand and consent to the administration of the advised medicine and allow the pharmacist to use the information I have supplied to keep as medical records (in line with GPDR). I also agree to pay a £10 consultation fee. If a treatment is administered after the consultation, this fee is deducted from the cost of the treatment. If no appointment is booked after assessment of the consultation form, this fee is non-refundable.

Yes

Personal Details

Name (required)

Date of Birth (required)

Contact Number Mobile

Emergency Telephone Number

Email (required)

GP surgery name (required)

Travel Details

Destination(s)

Date of Departure

Duration

Vaccines required:
UnknownCholeraHepatitis AHepatitis A PaediatricHepatitis BHepatitis A + TyphoidJapanese EncephalitisMMRMeningitis ACWYMeningitis BRabiesTetanus Diptheria PolioTyphoidShinglesChicken PoxYellow FeverPaediactric Hep A+B

Medical history

Do you have any allergies?
YesNo

Do you have any medical conditions?
YesNo

Do you take regular medicines?
YesNo

Are you pregnant or breastfeeding?
YesNo

Have you had a severe reaction following an injection?
YesNo

Have you ever fainted following an injection?
YesNo

Do you have a bleeding or clotting disorder?
YesNo

Are you taking any blood thinners?
YesNo

Do you have any long-term chronic illness?
YesNo

Do you have a disease/disorder that lowers your immune system (i.e. cancer /HIV)
YesNo

Are you having treatment that lowers your immunity? (i.e. steroids, radiotherapy, Chemotherapy)
YesNo

Have you had immunoglobulin or blood transfusion within the last 3 months?
YesNo

Insert names of any other travellers who need travel vaccinations:

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