Please complete the following form to request immunisation appropriate to your travel plans together with advice on anti-malarial drugs.
Failure to complete the form correctly and in full may delay your vaccination programme.
PLEASE NOTE: IF YOU ARE TRAVELLING IN LESS THAN 6 WEEKS, WE WILL BE UNABLE TO COMPLY WITH YOUR REQUEST. PLEASE BE VERY SPECIFIC WHEN SUPPLYING US WITH TRAVELLING INFORMATION. PLEASE SUPPLY US WITH THE NAME OF THE COUNTRY, THE REGION, AREA AND TOWN YOU ARE TRAVELLING TO.
You are strongly advised to visit www.fitfortravel.nhs.uk/ to obtain the latest travel information for the area you are visiting
Please give details of any other vaccinations you have received
Please give details
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.
I consent to my information being used for the purposes described above and wish to submit this online form to
Kessington Medical Centre
85 Milngavie Road, Bearsden, Glasgow, G61 2DN.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.