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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