travel clinic enquiry form | Highland Pharmacy

Preferred Pharmacy

First name

Last name

Birthday

Day

Month

Year

Address

Phone Number

Email

GP Practice

Medical history

Drug History

Drug Allergies

Areyou allergic to the following, please select all that apply.

Any previous reaction to vaccines

Current health conditions

Are you pregnant?

Yes

NO

Unknown

Not applicable

Are you breastfeeding?

Yes

No

Travel itenary. Please include dates of arrival/ departure. Number of weeks at each destination.

Type of trip (please select all that apply)

Area to be visited

Type and condition of accommodation

File upload -Please attach your vaccine history, either a pdf or photo would be great. This is available from your GP practice.

Can you please describe the type of activities you are taking part in i.e. Doing a safari: adventure sports: medical treatment, attending mass gathering such as Hajj or sports. Cycling, Running?

Travel Clinic Enquiry Form Remember to request your vaccine history from your GP surgery. You can upload the file or an image of it below.

Travel Clinic Enquiry Form

Remember to request your vaccine history from your GP surgery. You can upload the file or an image of it below.