St Peter's Travel Clinic | Travel Clinic Brighton | Travel Vaccinations Brighton | Travel Injections Brighton

01273 606636

Booking an Appointment

Please fill out the form below and press the submit button. Once we have received your form, we will then send you a text message allowing you to make an online booking.

Please note this may take up to 72 hours.

If you are travelling within the next 4 weeks please call us on:

01273 606636

A £15 consultation fee will be charged for private patients.

Please complete the form below.

Name: *

Email *

Date of birth *

Address *

Contact number *

Gender

Country of Origin

Date of departure *

Emergency contact number *

Total length of trip

Countries to be visited and exact location *

City or Rural

Length of stay

What accommodation do you plan to stay in *

Hotels

Hostels

Camping

Staying with local families

Air B and B

Cruise Ship

Please list any activities you are planning to undertake while your away e.g. Diving, altitude trips, cycling,

If you have any allergies, please list them here

Have you, or anyone in your family, had a severe reaction to a vaccine or malaria medication before? *

Yes

Tendency to faint with injections *

Yes

Any surgical operations in the past? e.g Open heart surgery, spleen or thymus gland removal *

Yes

Recent Chemotherapy/Radiotherapy or Organ Transplant? *

Yes

Anaemia, Bleeding or Clotting Disorders? (including history of DVT) *

Yes

Heart Disease (Including Angina) or High Blood Pressure? *

Yes

Diabetes *

Yes

Epilepsy/Seizures (or in a first degree relative) *

Yes

Additional Needs/or Disability *

Yes

Stomach complaints * e.g Crohns, IBS, Ulcers

Yes

Liver or Kidney problems *

Yes

HIV/Aids *

Yes

Immune system condition. Including issues with/removal of your spleen *

Yes

Mental health illness (including anxiety and depression) *

Yes

Neurological (nervous system)Illness *

Yes

Respiratory (lung) disease *

Yes

Rheumatology Conditions *

Yes

Are you or your partner pregnant or planning a pregnancy? *

Yes

Are your breastfeeding?

Yes

N/A

Any other conditions

Yes

If you answered yes to any of the questions above please provide more information here:

Are you currently taking any medication? Please include any prescribed and/or purchased medication.

Please provide any information on any vaccines or malaria tablets taken in the past:

Terms * On completing the above form, you will be contacted so that we can arrange an appointment for you. All the information you provide will be handled in accordance with our Privacy Policy. This can be found at
https://www.stpetersmedicalcentre.co.uk/practice-policies

Please tick the box to agree to St Peter's Health Centre Privacy Policy.

I Agree

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Contact Details:

Telephone:
01273 606636

Address:
30-36 Oxford Street,
Brighton, BN14LA, UK

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St Peter's Travel Clinic | Travel Clinic Brighton | Travel Vaccinations Brighton | Travel Injections Brighton

01273 606636

Book now

Book now

Booking an Appointment

01273 606636

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