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19 Canonbury lane
Islington
London
N1 2AS

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19 Canonbury lane
Islington
London
N1 2AS

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Travel Form

Dermacia Travel Form

Please fill in the form below prior to your appointment. Our pharmacy team will review your details before your appointment

By completing the form below you agree to your data being processed by Dermacia in accordance with out privacy policy

Travel Form

Fill in your details and one of the team will be in touch to discuss your vaccination requirements

Patient Details

Title

Gender

Full Name

Date of birth

Email

Phone

Patient Address

GP Name and Address

Would you like your GP to be notified of this consultation?

Yes

No

Dates, Itinerary and purpose of trip

Date of departure

Return date or overall length

1st country to be visited and length of stay

1st country info - remote? Trek? Medical access? Altitude?

2nd country to be visited and length of stay (if applicable)

2nd country info - remote? Trek? Medical access? Altitude? (if applicable)

3rd country to be visited and length of stay (if applicable)

3rd country info - remote? Trek? Medical access? Altitude? (if applicable)

4th country to be visited and length of stay (if applicable)

4th country info - remote? Trek? Medical access? Altitude? (if applicable)

5th country to be visited and length of stay (if applicable)

5th country info - remote? Trek? Medical access? Altitude? (if applicable)

Personal Medical History

Are you feeling well today?

Yes

No

Have you had any immunizations in the past 4 weeks?

Yes

No

Do you have any recent or past medical history of note?

Yes

No

Do you take any current or repeat medicines or are you taking halofantrine?

Yes

No

Do you have any allergies to any medicines, latex or eggs?

Yes

No

Have you had a serious reaction to a vaccine, antimalarial or doxycycline before?

Yes

No

Do you known if you are hypersensitive to mefloquine or related compounds (e.g.quinine, quinidine) or excipients?

Yes

No

Do you or any of your family suffer from epilepsy?

Yes

No

Do you have a past history of black water fever?

Yes

No

Do you have severe impairment of liver function?

Yes

No

Do you suffer from any blood disorders such as thalassaemia or sickle cell anaemia?

Yes

No

Have you recently undergone radio therapy, chemotherapy, steroids treatment?

Yes

No

Do you have any history of the following: anxiety, depression, heart, lung, spleen, liver,kidney, immunity, blood conditions, disorders, diabetes, immunity, HIV-AIDs?

Yes

No

If you have answered yes to any of the above, please provide details

Vaccination History (Please add dates)

Tetanus

Polio

Diphtheria

Typhoid

Hepatitis A

Hepatitis B

Meningitis

Yellow Fever

Influenza

Rabies

Jap B Enceph

Tick Borne

Other

Malaria Tablets

Women only

Are you pregnant or planning a pregnancy?

Yes

No

Are you breastfeeding?

Yes

No

Additional Information

Please write below any further information which may be relevant e.g. medicines, conditions

Acknowledgement

I agree to my data being processed in accordance with Dermacia's privacy policy

I agree

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Open 7 days a week

Mon - Fri 9am - 7pm
Saturday 9am To 6pm
Sunday 10am To 4pm

19 Canonbury lane
Islington
London
N1 2AS
[email protected]
0207 226 2780
Mon - Fri 9am - 7pm
Saturday 9am - 6pm
Sunday 10am - 4pm

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Pharmacy Services and Clinics

Pharmacy Services
Blood Tests
Weight Loss Clinic
Osteopathy Clinic
Podiatry Clinic
Travel Clinic

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DERMACIA (UK) LIMITED | Company Registration No.:08470714 | VAT Number 177 9283 54 Dermacia Pharmacy is a registered trade mark serial number. 012114914 GPhC Premises Registration Number: 2061090, Superintendent Pharmacist: Mrs E Alexandrou

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