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Travel Vaccination Booking Form

Please complete a questionnaire for each member of your travel party. 

Once we have received your completed form, a member of our Reception staff will contact you by phone within 1 working day to arrange an appointment date and time. If you have had any travel vaccinations previously, it would be extremely useful if you could bring any details about them (eg your 'yellow book') along with you to your appointment.

Gender
Have you attended the Travel Health service here before?

Travel Details

Details of your trip

Type of Accommodation
Area of Accommodation
Are you planning to work during your time abroad?
Do you plan to travel with children?
Do you plan to undertake any sports, during your trip?
Does your trip include the Hajj pilgrimage to Mecca?

Medical history

Have you ever attended a GP or hospital doctor for any of the following:

Respiratory illness including asthma
Cardiovascular illness including raised blood pressure
Digestive illness / Hepatitis / Jaundice
Blood clots in the leg or lung
Diabetes
HIV
Cancer / leukaemia
Fainting / fits / blackouts / epilepsy / convulsions
Rheumatism / joint or back pain
Anxiety / depression / psychiatric illness
Ear / Eye problems
Are you allergic to eggs?
Have you ever had a reaction to a vaccine in the past?
Have you ever had any other medical issues not mentioned above?
Do you smoke?
Are you pregnant or breast feeding?
Trying to conceive?

You must tell your travel doctor or nurse if you could be pregnant at the time of vaccinations or travel, as some of the vaccinations or anti-malaria tablets are not recommended in pregnancy

Mercer's Medical Centre is part of Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn