Happy Vaccs Travel Clinic

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Personal Details

Private Happy Vaccs Travel Vaccination Clinic: If you are not registered with Lambgates Health Centre and would like to use our Happy Vaccs Travel Clinic please complete the below travel vaccination assesment form, this will also create a temporary registration status for you at our pracitce. We will require a copy of your immunisation history, please email this to ddicb.c81106@nhs.net (please ensure your name, DOB and ' Travel Vaccination Clinic' is clearly stated on your email.

Title:

Please double check you've entered the correct email address

Dates and Trip Details

Holiday Type: *

Type of Trip: *

Accommodation: *

Travelling: *

Staying in area which is: *

Planned Activities: *

Personal Medical History

Including diabetes, heart or lung conditions

Have you ever had a serious reaction to a vaccine given to you before?:

Does having an injection make you feel faint?:

Do you or any close family members have epilepsy?:

Do you have any history or mental illness including depression or anxiety?:

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?:

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?:

Have you ever had any of the following vaccinations / malaria tablets?:

Signed & Dated

Type your full name to sign this form

This form is automatically dated upon submission.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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