BBC Health News

Theresa May calls for mental health to be priority16 Jun 2019 22:37Tackling mental health problems needs 'urgent attention', says the prime minister.
Lyme disease has 'dominated' my life17 Jun 2019 00:07Morven-May MacCallum speaks out as GPs are urged to be vigilant about the infection spread by ticks.
End-of-life care not 'culturally competent'15 Jun 2019 02:02A study hopes to boost the small number of black and Asian people using end-of-life care services.
Deadly Ebola outbreak 'not global threat'14 Jun 2019 19:10But World Health Organization says it is an emergency in the Democratic Republic of Congo and needs more funding.
Listeria outbreak: Health secretary orders NHS food review15 Jun 2019 14:34It comes as two more patients die in an outbreak linked to hospital sandwiches and salads.
Tattoo parlours pose infection risk, warn health experts14 Jun 2019 02:10With one in five adults now having a tattoo, more should be done to protect the public, a report says.

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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.

Appointment Details

Appointment datePlease provide in the format DD/MM/YYYY

Appointment timeHH:MM

2 Your Details

Title

First Name(s)

Surname

Home Address

Postcode

Home Phone Number

Mobile Phone Number

Work Phone Number

Date of BirthPlease provide in the format dd/mm/yyyy

3 Your Travel Arrangements

What date are you leaving the UK?Please provide in the format DD/MM/YYYY

Is the trip holiday or work?

4 Destination(s)

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

Country 1

Name

Which area are you staying in? (Please be exact)

Please give dates of your stay

Please give details of your accommodation (hotel, private house, camping etc)

Country 2

Name

Which area are you staying in? (Please be exact)

Please give dates of your stay

Please give details of your accommodation (hotel, private house, camping etc)

Country 3

Name

Which area are you staying in? (Please be exact)

Please give dates of your stay

Please give details of your accommodation (hotel, private house, camping etc)

Will you be visiting more than three countries?

Are you stopping elsewhere en-route?

5 Previous Immunisations

Please state whether you have had the following immunisations, along with the date given.

Tetanus

Ever Had?

Typhoid

Ever Had?

Cholera

Ever Had?

Rabies

Ever Had?

Hepatitis A

Ever Had?

Polio

Ever Had?

Meningitis

Ever Had?

Yellow Fever

Ever Had?

Hepatitis B

Ever Had?

Diphtheria

Ever Had?

Please give details of any other vaccinations you have received

6 Further Information

Have you had any antibiotic treatment in the last 8 weeks?

Have you suffered from depression or any other psychiatric illness?Further info: certain anti-malarial tablets can, in a small percentage of people, exacerbate epilepsy or Psychiatric illness.

Do you have epilepsy?

Do you have medical problems requiring regular medication or check ups?

Have you taken any steroids or had immunosuppressive therapy e.g. chemotherapy in the last 3 months?

Are you allergic to any medicines?

Have you ever reacted badly to any vaccine?

Are you pregnant or planning a pregnancy in the next 6 months?

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.

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.

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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