|
To help
us to plan a vaccination schedule in good time for your journey, please
complete and return a copy of this form for each member of your party
at
least 1 month before your departure.
|
Name |
Age |
| |
|
|
Address |
Telephone No.
|
-
What country and town are you visiting?
-
Will there be any stopovers? Y[
] N [ ]
(please tick)
-
If yes to 2. then
where?
-
When do you leave?
-
When do you return?
-
What is the nature of
your travel? (Please tick)
|
Business |
[
] |
Holiday |
[
] |
| Touring |
[
] |
Camping |
[
] |
|
Caravanning |
[
] |
Self-Catering |
[
] |
|
City Break |
[
] |
Beach Resort |
[
] |
|
Adventure |
[
] |
Staying with friends/relatives |
[
] |
-
What
vaccinations have you ever had
?
(give dates if you can remember)
|
Polio |
[
] |
Diphtheria |
[
] |
|
Tetanus |
[
] |
Typhoid |
[
] |
|
Hepatitis_A |
[
] |
Yellow_Fever |
[
] |
|
Others |
[
] |
|
|
Please leave
the completed form at reception and call back in 48
hours to find out what vaccinations you need.
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of page
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