0113 221 3533
0113 873 0242
Out Of Hours: 07597 028245
info@sfvaccinations.co.uk
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Home
Services
Travel Clinic
Antimalarials
Country Recommendations
Travel Vaccinations
Occupational Health Services
Occupational Health Blood Test
Occupational Health Vaccination
Medicals
Private Blood Tests
Private Vaccinations
Corporate Services
On-Site Vaccination Clinic And Testing Services
Employee Health And Wellbeing Checks
WellBeing Clinic
Chronic Migraine Treatment
Hyperhidrosis Botox Treatment
Vitamin Deficiency Treatmeant
Well Being Services
Covid-19 Test and Services
Testimonials
Contact
Book An Appointment
First Name
*
Last Name
*
Date of Birth
*
Your weight in KG
*
Address
*
Post Code
*
Phone Number
*
Email
*
Date of Departure
*
Total trip length (in days)
*
Do you plan to travel abroad again in the future *
Yes
No
Type of Trip
*
Type of Trip
Holiday
Business Trip
Expatriate
Volunteer Work
Health Care Worker
Staying in Hotel
Safari
Pilgrimage
Medical Tourism
Back Packing
Camping / Hostels
Adventure
Visiting Friends or Family
Other
Country and Location to be visited
*
- Long stay travellers (Over 4 weeks)
- Long stay travellers (Over 4 weeks)
Additional risks present: (Tick if applies)
Additional risks present: (Tick if applies)
Those more at risk of injury/accidents
Yes
Individuals with underlying conditions
Yes
- Travelling for medical procedures abroad
Yes
- Those at occupational risk
Yes
- Visiting friends and family
Yes
- Visiting areas of poor sanitation
Yes
- Visiting rural areas
Yes
- Other risk factors
Yes
Are you fit and well today? *
Yes
No
Are you fit and well today?
*
Have you been diagnosed with any allergies?
*
Yes
No
If you have been diagnosed with any allergies? Please give more details
*
Have you ever suffered a severe reaction to a vaccine?
*
Yes
No
If you have suffered a severe reaction to a vaccine? Please give more details
*
Have you been diagnosed with any blood conditions?
*
Yes
No
If you have been diagnosed with any blood conditions? Please give more details
*
Have you ever had any surgical operations?
*
Yes
No
If you ever had any surgical operations? Please give more details
*
Have you recently undergone chemotherapy/radiotherapy/an organ transplant?
Yes
No
If you have recently undergone chemotherapy/radiotherapy/an organ transplant? Please give more details
*
Have you been diagnosed with any heart conditions?
*
Yes
No
If you have been diagnosed with any heart conditions? Please give more details
*
Have you been diagnosed with diabetes?
*
Yes
No
If you have been diagnosed with diabetes? Please give more details
*
Have you been diagnosed with any disability?
*
Yes
No
If you have been diagnosed with any disability? Please give more details
*
Do you suffer from any gastrointestinal (stomach) complaints? *
Yes
No
If you suffer from any gastrointestinal (stomach) complaints? Please give more details
*
Have you been diagnosed with any liver or kidney problems?
*
Yes
No
If you have been diagnosed with any liver or kidney problems? Please give more details
*
Have you been diagnosed with epilepsy or have a history of seizures?
*
Yes
No
If you have been diagnosed with epilepsy or have a history of seizures? Please give more details
*
Have you been diagnosed with HIV/AIDS?
*
Yes
No
If you have been diagnosed with HIV/AIDS? Please give more details
*
Have you been diagnosed with an immune system condition?
*
Yes
No
If you have been diagnosed with an immune system condition? Please give more details
*
Do you have any mental health issues?
*
Yes
No
If you have any mental health issues? Please give more details
*
Have you been diagnosed with any neurological illness?
*
Yes
No
If you have diagnosed with any neurological illness? Please give more details
*
Have you been diagnosed with any respiratory (lung) disease?
*
Yes
No
If you have been diagnosed with any respiratory (lung) disease? Please give more details
*
Are you or your partner pregnant or planning a pregnancy or breastfeeding?
*
Yes
No
If you or your partner is pregnant or planning a pregnancy or breastfeeding? Please give more details
*
Do you suffer from or been diagnosed with any rheumatological (joint) conditions?
*
Yes
No
If you are suffering from or been diagnosed with any rheumatological (joint) conditions? Please give more details
*
Have you been diagnosed with any spleen problems?
*
Yes
No
If you have been diagnosed with any spleen problems? Please give more details
*
Do you have any other conditions?
*
Yes
No
If you have any other conditions? Please give more details
*
Have you previously had the following vaccines?
Influenza
*
Yes
No
Not Sure
Date
Tetanus/polio/diphtheria
*
Yes
No
Not Sure
Date
MMR
*
Yes
No
Not Sure
Date
Typhoid
*
Yes
No
Not Sure
Date
Hepatitis A
*
Yes
No
Not Sure
Date
Hepatitis B
*
Yes
No
Not Sure
Date
Cholera
*
Yes
No
Not Sure
Date
Pneumococcal
*
Yes
No
Not Sure
Date
Meningitis
*
Yes
No
Not Sure
Date
Rabies
*
Yes
No
Not Sure
Date
Tick-borne Encephalitis
*
Yes
No
Not Sure
Date
Japanese Encephalitis
*
Yes
No
Not Sure
Date
Yellow Fever
*
Yes
No
Not Sure
BCG
*
Yes
No
Not Sure
Malaria Tablets
*
Yes
No
Not Sure
What medication are you currently taking (whether prescribed by a GP, from hospital, over-the-counter or from a pharmacy)?
*
Is there any additional information you wish to let us know?
*
Consent
*
I confirm that the information provided by me is accurate and to the best of my knowledge. I am aware this is a private clinic where I will be charged for the service and products received according to the current price list. I agree information obtained during the service may be shared with other healthcare professionals for the best interests of my health and to ensure the healthcare professional can prescribe the appropriate treatment. Further information on how we use your data is available on our vaccination website [www.sfvaccinations.co.uk].
We may wish to send you information about products/services that may be relevant to you
Yes
No Thanks
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*
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