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Travel Vaccinations

To make it easier for our patients you can now complete the following form to request immunisation appropriate to your travel plans together with advice on anti-malarial drugs, after completing and submitting the form below contact the surgery to make an appointment with the practice nurse. The nurse will then be able to give you the correct vaccinations for your travel.

Failure to complete the form correctly and in full may delay your vaccination programme.

1Your Details

2Your Travel Arrangements

3Destination(s)

Please give details of which countries and areas you are visiting along with the dates of your stay.

4Previous Immunisations

If you have had the following immunisations please provide the date given

5Further Information

Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.

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.


Your Neighbourhood Professionals. Just a Click Away! Birch Healthcare Services
Queen Street, Cheadle, Stoke-on-Trent, ST10 1BH
  • Telephone 01538 753771
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Your Neighbourhood Professionals. Just a Click Away! Birch Healthcare Services
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