Please complete the pre-consultation form below. Upon successful completion, you will be required to pay a £20 consultation fee. If during your consultation you purchase vaccinations or anti-malarials, we will refund the £20 consultation fee. Upon receipt of your form submission and consultation fee, a pharmacist will contact you to arrange a visit to the clinic.

Patient's personal details:


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Title *:

Forename *:

Surname *:

Email Address *:

Mobile *:

Gender *:

Date of Birth *:

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Address *:

GP Name *:

GP Telephone *:

GP Address *:

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

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Dates, Itinerary and purpose of trip:


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Departure Date *:

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Return date or overall length *:

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Country Length of Stay

Information about your trip:


Please put a tick in the box next to each area that applies to any part of your trip

 

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Reason(s) for Travel *

HolidayBusiness TripVisiting friends/relativesExpatriate/long stayPilgrimageVolunteer workHealthcare worker

Other:

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Type(s) of Holiday *

PackageSelf OrganisedStaying in a hotelCruisingCamping/hostelsBackpacking/trekkingSafariMedical Tourism

Other:

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Planned Activities *

AdventureLeisureDivingRelief Aid/Work

Other:

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Do you have travel health insurance? *
YesNo

I am travelling *:
AloneIn a groupWith Family

 

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Travel and Transport *

WalkingTrekkingClimbingCarTrainTramsCoachPlaneBoatShipTaxiRickshawCable cars

Other:

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Accommodation *

Family HomeHotel (Star Rating)Camp/CaravansHostelVillaOwn Tents

Other:

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Medical Access *

Easy rapid access to good doctors (within 24 hours)Difficult access to good doctorsMedical access is going to be compromisedEasy access to good hospitals (within 24 hours)Difficult access to good hospitals

Other:

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Personal medical history:


Tick which of the following applies to you (reconfirmed at each appointment)

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Are you feeling well today?
YesNo

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

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

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

Do you have a past history of black water fever?
YesNo

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

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

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Have you had any immunisations in the past 4 weeks?
YesNo

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

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

Do you or any of your family suffer from epilepsy?
YesNo

Do you have severe impairment of liver function?
YesNo

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

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Vaccination History:


If you have had a vaccine, antimalarial or doxycycline before, please enter the date

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Tetanus

Typhoid

Meningitis

Rabies

Polio

Hepatitis A

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Yellow Fever

Jap B Enceph

Diphtheria

Hepatitis B

Influenza

Tick Borne

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Women only:


Select which of the following applies to you

Are you pregnant or planning a pregnancy?
YesNo

Are you breastfeeding?
YesNo

Please write below any further information which may be relevant e.g. medicines, conditions... (We require information about all your medical conditions and medication you have take)