Whiteacres Travel Form

Please see full details of travel services available at Whiteacres here: Travel Vaccinations - Whiteacres Medical Centre

Important: We require at least 6 weeks notice before you travel. Not all travel vaccines are available on the NHS at Whiteacres and you may need to consult a private travel clinic.

Why do I have to give 6 weeks notice?

Some vaccines need to be ordered. We do not hold stock of all travel vaccines.
Depending on the location where you are going, some vaccines need to be administered weeks ahead of your holiday to ensure immunity and effectiveness.
Some vaccines require several doses prior your holiday over 3 or 4 week period to ensure immunity and effectiveness.

After submitting we will be in touch withn 7 days to explain the next steps. If you have not heard back from us after 7 days please contact the surgery.

Whiteacres Travel Form

IMPORTANT! Tick to confirm departure date is at least 6 weeks from today's date. If not, please contact a private travel clinic and do not submit form. Form is for travellers on same holiday. If holiday differs, please submit seperate forms.

Main Contact Details

Traveller 1 Full Name

Traveller 1 Date of Birth

Destination of travelPlease list any destinations you are travelling to and how long you will be spending in each destination

Dates of travelPlease enter the dates of your trip including start and finish dates. Please note that we need at least 6 weeks notice.

Have you ever had any serious reactions to previous vaccines (if known)?Please enter as much information as possible

Is there any other information you think we should know?

Please enter details for ALL travellers below. If travelling alone please scroll to the bottom off the form.

Traveller 2 Full Name

Traveller 2 Date of birth

Traveller 2 Have you ever had any serious reactions to previous vaccines (if known)?

Traveller 2 Is there any other information you think we should know?

Traveller 3 Full Name

Traveller 3 Date Of Birth

Traveller 3 Is there any other information you think we should know?

Traveller 3 Have you ever had any serious reactions to previous vaccines (if known)?

Traveller 4 Full Name

Traveller 4 Date Of Birth

Traveller 4 Have you ever had any serious reactions to previous vaccines (if known)?

Traveller 4 Is there any other information you think we should know?

Traveller 5 Full Name

Traveller 5 Date Of Birth

Traveller 5 Have you ever had any serious reactions to previous vaccines (if known)?

Traveller 6 Full Name

Traveller 6 Date Of Birth

Traveller 6 Have you ever had any serious reactions to previous vaccines (if known)?

Travellr 6 Is there any other information you think we should know?

Email Confirmation

Tick the box if you would like to receive an e-mail confirming the form has been received by Whiteacres Medical Centre.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Whiteacres Medical Centre • Maple Road, Malvern, WR14 1GQ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.