Travel Vaccination Form - Nantgarw Road Medical Centre

If you are travelling abroad, you may need vaccinations.
Please complete and submit this form so that we can assess the vaccination (s) you may need.
You can check which vaccinations you may need by clicking the link below.
Please try and book at least 4 weeks in advance of travel for maximum protection. Patients needing other travel vaccines not provided by the practice, or need specific travel advice for complicated itineraries, should contact a local specialist Travel vaccination clinic

Do I need a travel vaccine?

Name of patient

Address

Date Of Birth

Phone Number

Email Address

Further Information

List Destinations - Country or Resort (Include any stopovers on the journey)

Date of Travel

Length of Stay

TYPE OF ACCOMMODATION (e.g. hotel, self catering, camping, backpacking, etc )

Are you pregnant or might you be before you travel?

Yes

Please list any known allergies

Please select which Travel Vaccines you need?

Hepatitis A
Polio
Typhoid
Tetanus

Please try and book at least 4 weeks in advance of travel for maximum protection. Patients needing other travel vaccines not provided by the practice , or need specific travel advice for complicated itineraries should contact a local specialist Travel vaccination clinic