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:
*
/
Day
/
Month
Year
Date
Date of Return:
*
/
Day
/
Month
Year
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):
*
Rural
Urban
Remote
Jungle
High Altitude
Other
If other, please list location types here:
*
Type of travel and purpose of trip (please tick all that apply):
*
Holiday
Business Trip
Volunteer/Aid Work
Staying in a hotel
Cruise ship travel
Safari
Backpacking
Visiting friends/family
Medical treatment
Trekking
Other
If other, please list travel purposes here:
*
Accommodation Type (please tick all that apply):
Hotel
Relatives / family home
Camping
Hostel
Other
If other, please list accommodation here:
Travelling with:
*
Alone
With family / friend
In a group
Planned activities:
Trekking
Safari
Pilgrimage
Working with animals
Sports
Diving
Other
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?
*
Yes
No
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?*
*
Yes
No
Are you currently breastfeeding?
*
Yes
No
Travel Insurance
If you have a medical condition, have you informed your insurance company about it
Yes
No
Personal Details
Name
*
First Name
Last Name
Date of birth:
*
-
Day
-
Month
Year
For medical purposes, please indicate your sex assigned at birth:
*
Male
Female
Prefer not to say
Email
*
Confirmation Email
example@example.com
Phone Number
*
Continue
Appointment attended?
Yes
No
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: