Travel Form

  • This form is only to be filled in by patients registered at the University Medical Centre
  • You will need to submit one form for each member of your party.
  • Please be aware that you may need several appointments to complete your course of vaccinations.
  • Charges for vaccines are payable at the time of vaccination by CASH or CHEQUE only – we do not accept credit or debit cards.

UMC Travel Form

Please state the COUNTRY & AREA you will be staying in - also you need to include details of any COUNTRIES where you will be making a STOP-OVER however brief
Please enter in format DD/MM/YYYY
If Other please state
Please enter in format DD/MM/YYYY

Please indicate if and when you have had any of the following vaccinations:

Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY
Please enter in format DD/MM/YYYY