Appointments

You must enter a full Forth Valley region postcode to use this service. If you think there is an error please call us on 0800 130 3120.

Your name *

Your Date of Birth * dd/mm/yyyy

Preferred contact number *

Your email *

GP Practice *

If you will be submitting assessment forms for multiple travellers to be discussed in your consultation, please provide all names and dates of birth to allow us to identify all traveller's assessment forms required for the consultation.
**Please ensure a referral form is completed for each passenger travelling**

Date of Departure * dd/mm/yyyy

Date of Return * dd/mm/yyyy

Please list countries you plan to visit (include all countries within this travel, length of stay and itinerary) *

Please give details of length of stay and how remote you'll be from medical help *

Please select the type of holiday/accommodation (select multiple if applicable) *
HolidayCruiseBusinessBackpackingPilgrimageHotel/resortCamping/GlampingHostelsSafariRuralOther

Please give indication of planned activities (select multiple if applicable) *
Visiting friends/relativesTravelling aloneSports/adventureDivingAltitudeWorking with animalsHealthcare workMedical tourismHigh risk, including drug use, tattoos, unprotected sexTourist sightseeingPleasureVolunteer workVehicle hireWater sportsOther

Do you have any allergies, for example eggs, antibiotics, nuts? *

Please detail any current or repeat medications *

Please detail any recent or past medical history of note below, Please include conditions such as diabetes, heart/lung conditions, Immune problems or Cancer *

Do you have any dysfunction of or have you ever had your Spleen or your Thymus gland removed? *

Are you currently pregnant, planning a pregnancy soon or whilst away, or breastfeeding? *

Have you had any pregnancies since 2012? If yes, did you receive a Whooping cough vaccine during the pregnancy? *

Are you up-to-date with the standard UK vaccination schedule? **Including 2 x MMR** *
—Please choose an option—YesNo

Please tick all previous vaccinations you have received in the past (ensure you have the dates available for the phone consultations) *
Diptheria/Tetanus/PolioTyphoidHepatitis ARabiesJapanese encephalitisTick borne encephalitisMeningitisYellow feverCholeraBCG/TBCovidInfluenzaMMROther

Please enter any additional information you would like to share with the Travel Health Nurse you feel will help inform the Nurse before your contacted (optional)

By submitting this form you agree this information is accurate to your knowledge and understand the information provided will be used to assess travel health needs. If you have not given accurate information the advice provided may be incorrect. You also agree to the NHS contacting you about your submission to arrange appointments if required.

I agree that my personal information may be used to process this order in accordance to NHS Forth Valley's Privacy Notice.