PATIENT NAME
DATE OF BIRTH
GENDER
Male
Female
ADDRESS
TELEPHONE
EMAIL
YOUR G.P. DETAILS
DATE OF TRAVEL
DO YOU HAVE TRAVEL INSURANCE?
Yes
No
DO YOU CONSENT TO US CONTACTING YOUR GP?
Yes
";
No
";
COUNTRIES YOU ARE VISTING
GEOGRAPHICAL REGION
DURATION DAY(S)
PURPOSE OF TRAVEL
Tourism or Business for less than one month
";
Adventure
";
Cruise
";
Diving
";
Healthcare worker
";
Short-term ex-pat (less than 3 months)
";
Long-term ex-pat
";
Backpacker
";
Gap year
";
Volunteer worker
";
Medical tourism
";
Natural disasters
";
Pilgrimage
";
Visiting friends or relatives
";
Other reason
";
PREGNANCY STATUS
BREASTFEEDING
LAST PERIOD
N/A
I am not pregnant
I am pregnant
I am intending to get pregnant
N/A
I am not breasfeeding
I am breastfeeding
KNOWN MEDICAL CONDITIONS OR ALLERGIES
ADDITIONAL INFORMATION FOR CONDITION OR ALLERGY
CURRENT MEDICATION
DOSAGE & FREQUENCY
PRESCRIBED?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
VACCINES YOU HAVE RECEIVED IN THE LAST 10 YEARS
DATE ADMINISTERED (DD/MM/YYYY)
Is this request
for a child under
16 years of age?
No
Yes
By clicking
SEND
you agree to the International Travel Clinics Terms and Conditions
and that you have
full legal consent
for any child to receive treatment as necessary.