Travel Advice Questionaire

Full Name:               Date of Birth:

Second Name:        Date of Birth:

Third Name:            Date of Birth:

Fourth Name:          Date of Birth:

Address:                Tel. No:           

Destination, please be specific:    Duration of Stay:

Type of Holiday                                Date of Departure:

Further Information:     

Please submit this form at least 8 weeks prior to departure as some vaccinations need to be given well in advance.  NOTE:- not all vaccines are available on the NHS and may be chargeable, payment has to be made by either cash or cheque at time of vaccination. Debit or Credit Cards CANNOT BE ACCEPTED.   Also please allow 3 working days for this form to be processed and then ring 0844-815-1055 to enquire as to whether you need any vaccinations you may then make an appointment with the nurse if needed.

 

 

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