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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.
Please give details of which countries and areas you are visiting along with the dates of your stay.
If you have had the following immunisations please provide the date given
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.
I consent to my information being used for the purposes described above and wish to submit this online form to
The Tardis Surgery
Queen Street, Cheadle, Stoke-on-Trent, ST10 1BH.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.