Travel Clinic

Travel Clinic Consultation Form




Please provide details of your trip including all of the Countries you will visit

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Chicken Pox:
Cholera
DTP (Diptheria, Tetanus, Polio)
Hepatitis A (Adult)
Hepatitis A (Junior 1-17yrs):
Hepatitis B (Adult):
Hepatitis B (Junior 1-15yrs):
Hepatitis A + B (Combined):
Hepatitis A + B (Combined Paediatric 1-15yrs):
Japanese Encephalitis
Meningitis ACWY
Rabies
Tick-borne Encephalitis (Adult)
Typhoid (Injection)
Yellow Fever
HPV
MMR
Tick-borne Encephalitis (Junior)
Whooping Cough
Dengue Fever
Meningitis B
Shingles



Please provide some background Medical information

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Please complete the following Consent questions

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