• 5 Castle Hill Parade, West Ealing, London W13 8JP.

Travel Clinic Form

Travel Clinic Form

Save time and fill out your consultation form online below before you arrive. Please note if you are having a course of vaccines, you only need fill out this from once, not every time you visit us. If this is a different trip, then please fill it out.

1. Personal details








2. Travel Itinerary





3. Reason for travel and type of accomodation – Please tick all that apply

Travel Type
Accomodation Type

Yes Have you taken out travel insurance for this trip and if you have a Medical Condition, have you informed the insurance company about this? *

Medical History


For Woman only


Yes I confirm that i have no reason to be believe I am pregnant. All the information I have provided is true to my knowledge. I consent to vaccines being given and understand the risk and benefits of vaccines recommended. *


Previous history of vaccines or Malaria Tablets taken