Travel Consultation | Kildare Medical

Travel Consultation Form

Please complete your travel consultation form as soon as possible once you have made your appointment.

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Address

Eircode

Phone

Next of Kin

Next of Kin Phone Number

Name & Address of own GP if not a patient of KMC

Departure Date

Return Date

Please list all countries you plan to visit and duration of stay:

Travelling

Alone

With family/friend

In a group

Staying in Area

Urban

Rural

High Altitude

Planned activities (e.g. safari, trekking, diving)

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

Yes

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

Does having an injection make you feel faint?

Yes

Are you pregnant, trying to conceive or breastfeeding?

Yes

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

Yes

Do you have a Thymus Disorder, Myasthenia Gravis, Di George Syndrome or a Thymona

Yes

Name of vaccine and date received:

Please list all current medications you are taking (including over the counter medications):

I consent to this message being sent electronically to the practice. I have checked that the email address and phone number supplied are correct and consent to receiving medical information via email or text.

I agree to make payment of €30.

I understand that this fee is redeemable against the cost of vaccines if they go ahead.

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

Travel Consultation Form

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For Life Threatening Emergencies - Call 999 or 112