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  • 01902 333408
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Penn Surgery Providing NHS services
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Home > Travel Vaccination Questionnaire

Travel Vaccination Questionnaire

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

  • The surgery only provides a small number of travel vaccinations 
  • There maybe a charge for some vaccines
  • It is the patients' responsibility to contact the surgery after 5 working days for details of any immunisations or medications that may be required.

Please note if any of the following applies to you 

  1. You are travelling in less than 8 weeks
  2. You are visiting several countries over a long period

We advise that you contact a MASTA Travel Clinic for all your travel 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
Accommodation
Medical History

Women only


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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Penn Surgery

2a Coalway Road, Penn, Wolverhampton, WV3 7LR

  • 01902 333408
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