Kingsbridge Private Hospital
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Travel Vaccination Form

Please note that travel vaccinations are required 6 weeks before your date of departure. If it is less than 6 weeks before your trip please call 028 9066 7878 and we can advise you on how we can help.

Ideally to be completed by traveller prior to appointment. Our healthcare team can assist in completing this form, if needed.

If you wish to book an appointment at the Travel Clinic, please ensure you complete ALL fields in the form below. Incomplete forms may cause a delay with your appointment.

Travel Vaccination Form

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
Name*
DD slash MM slash YYYY

Information About Your Trip

DD slash MM slash YYYY
DD slash MM slash YYYY

Travel Itinerary

(if applicable)
(if applicable)
(if applicable)
(if applicable)
(if applicable)
(if applicable)
(if applicable)
(if applicable)
Purpose of Trip
Please tick all that apply

Medical History

Are you pregnant?
Are you breastfeeding?