Travel Clinic Form

Travel Vaccine Assessment and Request Form

If you are travelling as part of a group, each person must complete and submit their own form to the clinic.
Privacy Notice
Your information will be used to manage your booking and provide safe care. Details may include your contact information, travel history, and relevant medical information.

Most data is stored securely in the EU and accessed only by our clinical and admin teams. For appointment scheduling, your name and email address are stored securely in Calendly on servers in the United States.

We will not share your data with third parties unless required by law.

You have rights over your data, including access, correction, and deletion (subject to legal/clinical requirements).

For questions, please contact: travelclinic@hillconfed.co.uk.

Learn more about your rights at: ICO Website
Travel Information
Date of Departure:

DayMonthYear
Date
Date of Return:

DayMonthYear
Date
Countries visiting (open the dropdown box and begin typing to find specific country):
If other, please list countries here:
Type of Location(s) (Please tick all that apply):
If other, please list location types here:
Type of travel and purpose of trip (please tick all that apply):
If other, please list travel purposes here:
Accommodation Type (please tick all that apply):
If other, please list accommodation here:
Travelling with:
Planned activities:
If other, please list planned activities here:
Medical History
Please list any allergies you have (e.g. to eggs, antibiotics, nuts, etc):
Vaccination History:
If Other, please state details of vaccination and date:
Have you have a severe reaction to any vaccines in the past?
Please provide details of which vaccination(s) you had reactions to:
Pregnancy & Breastfeeding
Are you currently pregnant or planning to become pregnant within 3 months of travel?*
Are you currently breastfeeding?
Travel Insurance
If you have a medical condition, have you informed your insurance company about it
Personal Details
Name

First NameLast Name
Date of birth:

DayMonthYear
For medical purposes, please indicate your sex assigned at birth:
Email

Confirmation Emailexample@example.com
Phone Number
Format: 00000000000.
Appointment attended?
I confirm that I understand the information provided about the vaccination(s) and I consent to receive the vaccination(s).
Appointment Notes
Should be Empty:

Travel Vaccine Assessment and Request Form

Privacy Notice

Travel Information

Medical History

Pregnancy & Breastfeeding

Travel Insurance

Personal Details