Old Station Surgery

Search topics

Menu

Home
Admin Queries
Your Surgery
News
Events
Out of Hours
About The Cluster

Old Station Surgery

Brecon Road, Abergavenny, Monmouthshire, NP7 5AQ

01873 859000

Cymraeg

Select your Language

Search topics

Home
Admin Queries
Your Surgery
News
Events
Out of Hours
About The Cluster
More

Home
Admin Queries
Travel Vaccination Form

Travel Vaccination Form

Travel Vaccination Form

If you are traveling abroad, you may need vaccinations.

Please complete and submit this form so that we can assess the vaccination (s) you may need. There may be charge for vaccinations.

You can check which vaccinations you may need by clicking the link below.

Do I need a travel vaccine?

Name

Address

Date Of Birth

Phone Number

Email Address

Further Information

List Destinations - Country or Resort (Include any stopovers on the journey)

Date of Travel

Length of Stay

TYPE OF ACCOMMODATION (e.g. hotel, self catering, camping, backpacking, etc )

Are you pregnant or might you be before you travel?

Yes

No

Please list any known allergies

Please select which Travel Vaccines you need?

Hepatitis B (Course of 3)
Hepatitis B (Booster)
Japanese Encephalitis (Course of 2)
Japanese Encephalitis (Booster)
Rabies (Course of 3)
Rabies (Booster)

If 'other' please state what travel vaccinations you need

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

Yes

No

Thank you. Your message has been sent to your surgery.

Sorry, something went wrong. Please try again.

Old Station Surgery

Brecon Road
Abergavenny
Monmouthshire
NP7 5AQ

01873 859000

Quick Links

Home
Your Surgery
News
Health Resources
Admin Queries
Events
Website Accessibility Statement
Terms & Conditions
Privacy Policy

Download our app

©2024 Old Station Surgery - Cookie Settings

Website by Primary Care Online

We use cookies on our website. For full details please see our Privacy Policy. We would like your consent to use cookies that allow us to give you a personalised experience and advertise to you elsewhere on the internet. Click ALLOW if you’re happy for us to do this. You can also choose to disable all optional cookies by clicking DISALLOW.