Marino Medical - Travel Vaccine Consultation Form

In order to provide for your travel vaccine care we need to collect and keep information about your trip. The information will be used to create your personal medical record on the practice computer. Our practices are consistent with the Irish Medical Council guidelines and privacy principles of Data Protection Acts. Visit https://www.icgp.ie/data, for further details see our Practice Privacy Statement. 

All details in this form will be strictly confidential

 

 

Travel Information

Please complete your travel information, we will review and book your appointment
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Please select
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consent to this information being sent electronically to the practice.  I have checked that the email address and phone number supplied by me are correct and consent to receiving medical information via email or text.
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