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Travel Vaccinations

Please complete the following form to request immunisation appropriate to your travel plans together with advice on anti-malarial drugs.

Failure to complete the form correctly and in full may delay your vaccination programme.

Appointment Details
Please provide in the format DD/MM/YYYY
HH:MM
Your Details
Please provide in the format dd/mm/yyyy
Your Travel Arrangements
Please provide in the format DD/MM/YYYY
Destinations

Please give details of which countries and areas you are visiting along with the dates of your stay.

Country 1


Country 2


Country 3


Previous Immunisations

Please state whether you have had the following immunisations, along with the date given.


Further Information
Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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102 St Georges Road, Coventry, CV1 2DL

  • 02476 552531
  • stgeorges.road@nhs.net

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