Travel Consultation Form

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

First / Last name

Date of Birth

YYYY

Please select

Phone

Email Address

Departure Date

YYYY

Return Date

YYYY

Please list ALL Countries you plan to visit and duration of your stay (this will determine your travel vaccine requirements)

Travelling

Alone

With Family/Friend

In a group

Other:

Staying in Area

Urban

Rural

High Altitude

Planned activities (eg Safari, trekking, diving etc)

Do you have any recent or past medical history of note (including diabetes, heart or lung conditions)?

Yes

If yes, please list relevant medical history

Are you currently taking medication or do you have an illness that will suppress your immune system?

Yes

if yes, please list all current medication you are taking (including over the counter medication)

Do you have any allergies e.g. nuts, eggs, antibiotics etc?

Yes

Have you ever had a serious reaction to a vaccine given to you before?

Yes

Are you pregnant, trying to conceive or breastfeeding?

Yes

Name of Vaccine and date received

I 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.

Patient Consent - Digital Signature Required

I agree to the terms of service.

Verification