First name (shown in Passport)

Last name

Date of Birth

Day

Month

Year

Nationality

Contact number

Email

Please complete the sections below so we have the correct information about the countries you are visiting, the duration of travel and the type of travel you are undertaking.

Examples as below:

Thailand; Airbnb; 5/8/24-9/8/24; 5 days
Indonesia; Resort; 10/8/24- 12/8/24; 3 days

Purpose of trip

Your activities

Your Health

Any Allergies

No

If yes, please comment

Immunocompromised

No

If yes, please comment

Pregnant/Breastfeeding?

No

If yes, please comment

Planning to conceive within 3 months of return from travel?

No

If yes, please comment

Personal or strong family history of leg or lung blood clots?

No

If yes, please comment

Diabetes

No

If yes, please comment

Asthma or COPD

No

If yes, please comment

Hospital admission in the last 3 months?

No

If yes, please comment

Other medications

No

If yes, please comment

Your Vaccination History

Did you miss any of your childhood or scheduled vaccines?

No

If yes, please comment

Have you had your COVID vaccines?

Have you had the Flu vaccine?

Previous Travel Vaccines Example: Rabies; 5/8/24; N/A; sore arm

Please list by following this order: the vaccine you received, date (primary course), date (booster dose), any side effects that you experienced.

If applicable, please provide a copy of your vaccine card & yellow card certificate.

This is a checkbox.