Abercromby Family Practice

Grove Street, Liverpool, L7 7AF

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0151 295 3888



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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
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