• Pre Travel Checklist

    Pre Travel Checklist

  • Multiple vaccines may be recommended dependent on your destination(s). Vaccines are not available without first having a travel consultation. Travel Consult Fees and Vaccination Fees are payable on the day. Yellow fever consultations usually require 30 minutes per person. Please note, you may need a separate (nursing) appointment for the vaccine.

  • Patient Details

  • Date of birth*
     - -
  • Which ethnic group(s) do you belong to?*

  • Emergency Contact or Next of Kin

  • Trip Details

  • Departure date for this trip*
     - -
  • Who are you travelling with?*
  • Purpose of trip - select all that apply.*
  • Activities - select all that apply.*
  • Do you have travel insurance for this trip?*
  • Medical History*
  • Are you pregnant?*
  • Are you breastfeeding?*
  • Do you or your partner intend to become pregnant in the next 12 months?*
  • Are you up to date with your childhood vaccinations?*
  • Does having an injection make you feel faint or pass out?*
  • Have you taken medication or prevent Malaria in the past?*
  • Do you believe you need Yellow Fever vaccination?*
  • Rows
  • If I receive a vaccine at Riccarton Clinic, I would like my regular GP practice advised.*
  • Should be Empty: