Travel prescription questionnaire

Name *

First

Last

Date of Birth *

Email *

Address *

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

1. Who is this questionnaire being completed for? *

Me
An Adult (not me)
A Child

2. When are you planning to leave for your trip? *

Less than 4 weeks
More than 4 weeks

3. Please confirm your age *

4. Please confirm your birth gender *

Female
Male

5. Are you pregnant or breastfeeding? *

6. Do you currently have any of the following bleeding conditions? *

8. Are you currently taking warfarin medication? *

9. Have you ever had an anaphylactic reaction to a vaccination ? *

10. Do you need a vaccine for yellow fever ? *

11. Have you had malaria in the last 12 months? *

12. Do you have a kidney condition? *

13. Do you have a liver condition? *

15. Do you have any other medical conditions? *

16. Have you had any surgery or medical procedure? *

17. Please share your height and weight *

19. Are you taking any prescription medication? *

20. Do you have any allergies? *

21. Where did you receive your vaccinations as a child? *

UK
Ireland
Europe
Other

22. Have you ever experienced a reaction after a vaccination? *

23. Are your vaccinations as a child up to date? *

Yes
No
I cant remember

24. Have you had vaccinations in the past 10 years? *

25. If you need anti-millarials, which treatment would you prefer? *

I have no preference
I do not need this
Malarone
Doxycycline

26. Please share the date you are leaving for your trip *

28. How many countries are you planning to visit? *

29. Please share the name of the county/countries you are travelling to? *

30. What region in the country/countries are you visiting? *

33. Please confirm you have answered all questions with complete honesty and this treatment is for your personal use only *

Yes- I confirm this treatment is for me, and I have answered all questions honestly
No

34. Please confirm the following statement: That you will read all documents associated with your travel and vaccinations and speak with a Doctor if you are unsure with anything. You will also inform your GP on the treatments you receive and they will manage this for you going forward. *

Yes- I confirm I understand the statement written
No

35. Please upload a photo ID

Click or drag a file to this area to upload.

Price

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card

Get a Travel Vaccination