Travel Vaccination Questionnaire

This form must be completed 8 weeks prior to appointment / travel.

Please note if any of the following applies to you

  1. You are travelling in less than 6 weeks
  2. You are travelling to Pakistan for more than 4 weeks
  3. You are visiting several countries over a long period

WE ADVISE THAT YOU CONTACT A MASTA TRAVEL CLINIC FOR ALL YOUR TRAVEL VACCINE NEEDS SEE BELOW

MASTA Travel Clinic - Lloyds Pharmacy   TRAVEL VACCINATION CLINIC

24-28 Dudley Street
Sedgley
Dudley
West Midlands
DY3 1SB

0330 100 4106

Pennfields Pharmacy
248 Jeffcock Road
Wolverhampton
WV3 7AH

01902 341300

Please note:  It is the patients' responsibility to contact the surgery after 5 working days for details of any immunisations or medications that may be required.

Travel Vaccination Questionnaire
Medical History

Women only


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All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has 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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