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Consultation Form
Gender
Itinerary
Type of trip
Travelling party:
Accommodation
Staying area that is:
Health History
Any allergies for example to eggs, antibiotics, nuts or latex?
Have you had a serious reaction to a vaccine given to you before?
Does having an injection make you feel faint?
Answer:
Do you or any close family members have epilepsy?
Answer:
Do you have any history of mental illness?(for malaria treatment)
Answer:
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Answer:
If you answered yes to any of the last 4 questions, please explain:
Are you pregnant, planning pregnancy or breastfeeding?
Answer:
Vaccination History
Please select previous vaccines
Cholera
Hepatitis A
Hepatitis B
Japanese encephalitis
Measles-Mumps-Rubella
Meningococcal meningitis
Polio
Rabies
Tetanus-Diphtheria
Typhoid
Yellow Fever
You can also upload a screenshot or a scan of your previous vaccination records (up to 3 files).
Upload File #1
Upload supported file (Max 15MB)
Upload File #2
Upload supported file (Max 15MB)
Upload File #3
Upload supported file (Max 15MB)
By signing and submitting this form I confirm the information provided is accurate and I give permission for Caresol Travel and partner pharmacy to use this information to assess and advise on my travel health need.
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