Assesment - Advance

We have a limited supply of Hepatitis A & Hepatitis B vaccine available during the current national shortage.

Name*

First NameLast Name

Date of Birth*

DayMonthYear

E-mail*

example@example.com

Phone Mobile*

Address

Street Address

Street Address Line 2

CityCounty

Post Code

Reason For Vaccination*

Please select one

Date of Departure*

Return Date*

Please give details of country to be visited, length of stay, and how remote you'll be from medical help*

Type of Trip*

Holiday type eg Package, Self organised, Backpacking, Camping, Cruise ship, Trekking, pilgrimage, on business, relief/aid work *

Accommodation eg Hotel, Relatives / family home, camping*

What type of area are you visiting*

Urban - General Tourist AreaRuralAltitudeOther

Do you have any of the following planned activities?*

SafariAdventureNONEOther

Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)*

YesNo

Do you have any allergies for example to eggs, antibiotics, nuts?*

YesNo

Have you ever had a serious reaction to a vaccine or antimalarials given to you before?*

YesNo

Does having an injection make you feel faint?*

YesNo

Do you or any close family members have epilepsy?*

YesNo

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

YesNo

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?*

YesNo

Women only: Are you pregnant or planning pregnancy or breast feeding?

YesNo

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about his?*

YesNoNot sure

Please provide any further information which may be relevant

Vaccination History: Please tick any travel vaccine that you have previously been given (Please click the + button to add more)

Do you know what vaccinations you require?*

Vaccination(s) Need: If you know what you need please tell us what vaccination's you need. (Please click the + button to add more)

If you do not know what vaccinations you need we can advise you when we have assessed your form.

Preferred Appointment

Plan Ahead - After 48 hours (2 Working Days)Express Service - within 48 hours ( I understand this upgrade incurs a £25 non-refundable charge)I would prefer a specific date

Preferred Appointment - we will do our best to accommodate your request. We will confirm your appointment within 24 hours. Please ensure you choose a date 2 full working days ahead

DateHourMinutesAM/PM Option

Preferred Appointment . Please note this will upgrade your service to Express which will incur a non-refundable £25 charge We will confirm your appointment as soon as possible during opening hours.

DateHourMinutesAM/PM Option

Preferred Appointment 1 (we will do our best to accommodate you). We will confirm your appointment within 24 hours. If you require an appointment within two working days please re-select 'Express Service'

DateHourMinutesAM/PM Option

Preferred Location

BramhallHazel GroveI'm flexible

Cheshire Travel Clinic Charge a £25 fee to assess your risk assessment - this is FULLY refunded against any vaccinations you have with us*

GBPRefundable against your vaccines (EXPRESS APPOINTMENTS NON REFUNDABLE)

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Billing Address*

Street Address

Street Address Line 2

City

Postal Code

By submitting this form I agree to following terms & conditions.

I understand the £25 is non refundable. If we cannot accommodate you in the next 48 hours we will either give you the option of a refund or to choose an advance appointment. If you choose an advance appointment your £25 will be refunded against your vaccine price. No quibble guarantee.

Signature: Please sign if possible

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Travel Risk Assessment Form