High Pastures Surgery

138 Liverpool Road North, Maghull, L31 2HW

NHS logo

0151 526 2161

FOREIGN TRAVEL IMMUNISATION REQUEST

 

* You do not need to complete all questions, only those relevant to you. *

To protect your privacy, this page uses SSL (Secure Sockets Layer) which is the standard security technology for establishing an encrypted link between the web server and your browser, ensuring all data passed between them remains private.

Items in bold are required for successful receipt of your message.

PATIENT DETAILS
 
Are you stopping on the journey?
If yes, where?
And for how long?
Are you staying in a hotel or private accommodation?
Will you camp or sleep rough? No
Have you previously been immunised against...
Tetanus Year
Polio Year
Typhoid Year
Meningitis Year
Cholera Year
Yellow Fever Year
Rabies Year
Hepatitis B Year
Hepatitis A Year
Others, e.g. Rubella
Year
Year
Do you have any medical problems requiring regular supervision? If yes, what is the problem?
Are you taking steroids?
Are you taking any other regular medication?
Are you pregnant?
Have you reacted badly to any previous vaccine?
Are you allergic to any medicines?
I confirm the above answers to be correct to the best of my knowledge and request immunisation as appropriate to my trip together with advice on anti-malarial drugs.
Please tick this box to confirm that you have completed your Travel Immunisation request and click the 'Submit' button to send this request to the practice