Kessington Medical Centre
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Key Information

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Travel Vaccinations

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

Your Details
Date Of Birth
Your Travel Arrangements
Country 1
Country 2
if none, please write none
Country 3
Dates of your stay, if more than one visit
Previous immunisations

Please give details of any other vaccinations you have received

Current medications or conditions

Please give details

For Office Use Only
Please do not complete this section. For internal use only

Privacy Protection

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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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