Travel Questionnaire

If you are planning to travel abroad, please complete and submit the following form at least 4 - 6 weeks before you are travelling. We will contact you to book an appointment once the Practice Nurse has looked over your form and assessed which vaccinations you require.

Failure to complete the form correctly may delay your vaccination programme.

If there are multiple people travelling together who are registered with Dr Sani & Partners, one form must be completed per person.

Your Details

Title

First Name

Surname

Date of Birth

Address

Contact Telephone Number

Your Travel

Destination

What date are you leaving the UK?

What is the date of your return?

Are you pregnant?

Are you breast feeding?

For official use ONLY - To be completed by Clinician

Risks

Does patient require an appointment?

Vaccinations Required

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Dr G. Sani & Partners • City of Coventry Health Centre, 2 Stoney Stanton Road, Coventry, CV1 4FS.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.