Travel Advice

Please provide as much information to enable us to give you accurate advice.

Ensure you submit the form at least 4 weeks before intended date of travel.

We will process the questionarre and pass it to the nurses, you will receive a response via email or text message in the next 3 working days.

Your Details

Full Name

Date of Birth

Mobile Tel No

Email address

Sex

Trip Dates

Departure Date

Duration

Trip Itinerary

Country 1

Duration

Availability of medical help

Country 2

Duration

Availability of medical help

Country 3

Duration

Availability of medical help

Personal Medical History

List all chronic medical conditions that you have (eg Diabetes, Heart or Lung Conditions etc)

List all allergies that you have (eg eggs, nuts, antibiotics)

If you have had a serious reaction to a vaccine in the past, which vaccine was it?

List all of your current medications (including oral contraception)

Have you recently suffered from any infection (eg heavy cold, flu or high temperature)?

Does having an injection cause you to feel faint?

Do you or any close family members have epilepsy?

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

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Have you taken out travel insurance?

If you have a medical condition, have you told your insurance company about it?

Are you pregnant, planning pregnancy or breast feeding?

Please provide any further information that might be relevant

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.

I consent to my information being used for the purposes described above and wish to submit this online form to The Lyndhurst Medical Centre • 41 Lyndhurst Road, Barnehurst, DA7 6DL.

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.