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Travel Vaccine Form

Help us to risk assess your travel

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Date of Birth
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Date of Travel
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Date of Return
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Destination

Give details of the countries you will be visiting, in the correct order, including any country you may be just passing through.

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Type of Travel

Select which of these best describes the purpose of your trip

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Personal Medical History

Give details of any conditions which may affect your travel plans.

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Vaccination History

Please let us know which vaccines you have previously been given and when

Tetanus
Tetanus
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Date
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Polio
Polio
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Date
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Diphtheria
Diphtheria
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Date
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Hepatitis A
Hepatitis A
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Date
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Hepatitis B
Hepatitis B
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Date
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Typhoid
Typhoid
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Date
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Meningitis
Meningitis
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Date
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Typhoid
Typhoid
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Date
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Yellow Fever
Yellow Fever
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Date
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Japanese B Encephalitis
Japanese B Encephalitis
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Date
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Tick-borne Encephalitis
Tick-borne Encephalitis
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Date
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Influenza
Influenza
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Date
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Links

Contact Us

  • 0345 900 7851

  • For all prescription enquiries please use the following email address:
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  • For all Administrative enquiries please use the following email address:
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  • For all private work enquiries please use the following email address:
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  • Please do not use this email for emergencies or clinical requests such as medication requests, changes or any test results.

Opening Hours

Buckley Medical Centre:
Monday - Friday:        8 am – 6.30 pm
Saturday - Sunday:    Closed

Glanrafon Medical Centre - Mold:
Monday - Friday:        8 am – 6.30 pm
Saturday - Sunday:    Closed