Pre-travel Questionnaire
To be completed by every traveller 16 years and older.
Full name
Date of birth
-
Day
-
Month
Year
Date
Email
Phone
Gender
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you enrolled with either Freemans Bay Medical, Mission Bay Doctors or Remuera Doctors?
Yes
No
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Vaccinations
Are you up to date with your childhood vaccinations?
Yes
No
Not sure
Have you had previous travel vaccines?
Yes (please bring in any vaccine records done by other clinics)
No
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Appointment request
Please book 48 hours in advanced
Have you booked your appointment yet?
Please Select
Yes (leave next section blank)
No
Preferred appointment date
-
Day
-
Month
Year
Date
Preferred appointment time
AM
PM
Any
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Travel Intinerary
Departure date
-
Day
-
Month
Year
Date
Who are you travelling with?
What is your reason for travel? (e.g. holiday, business volunteer work)
Are your travel plans (flights, accommodation, transfers, activities) booked yet?
Yes
No
Partially
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First Country
Destination
Type of accommodation (hotel, relative etc)
Is this mainly:
Urban
Rural
Don't know
Date you will arrive
-
Day
-
Month
Year
Date
Length of stay
Are you visiting any other countries?
Yes
No
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Second Country
Destination
Type of accommodation (hotel, relative etc)
Is this mainly:
Urban
Rural
Don't know
Date you will arrive
-
Day
-
Month
Year
Date
Length of stay
Are you visiting any other countries?
Yes
No
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Next
Third Country
Destination
Type of accommodation (hotel, relative etc)
Is this mainly:
Urban
Rural
Don't know
Date you will arrive
-
Day
-
Month
Year
Date
Length of stay
Are you visiting any other countries?
Yes
No
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Next
Fourth Country
Destination
Type of accommodation (hotel, relative etc)
Is this mainly:
Urban
Rural
Don't know
Date you will arrive
-
Day
-
Month
Year
Date
Length of stay
Are you visiting any other countries?
Yes
No
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Next
Fifth Country
Destination
Type of accommodation (hotel, relative etc)
Is this mainly:
Urban
Rural
Don't know
Date you will arrive
-
Day
-
Month
Year
Date
Length of stay
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Next
Thank you for completing
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