Consultation Form

/xsl/email/mailform.xslNational Travel ClinicsNTC[email protected]bradleyConsultation Form

Personal Information

First NameLast NameClinicGenderMaleMaleFemaleFemaleAgeDate of BirthNationalityPostcodeE-mailPhone

Next of Kin/Emergency Contact

First NameLast NameTelephoneOccupationCompany

Itinerary Details

DestinationDate of DepartureDate of Returna Is this a multi-destination trip?YesYesNoNoWill you be away from medical help at any of these destinations?YesYesNoNoUnsureUnsureType of TripBusinessBusinessPleasurePleasureOtherOtherHolidayTypePackagePackageSelf OrganisedSelf OrganisedBackpackingBackpackingCampingCampingCruise ShipCruise ShipTrekkingTrekkingAccommodationHotelHotelRelatives/Family HomeRelatives/Family HomeOtherOtherTravellingAloneAloneWith family / friendWith family / friendIn a groupIn a groupStaying in area which isUrbanUrbanRuralRuralAltitudeAltitudePlanned ActivitiesSafariSafariAdventureAdventureAltitudeAltitude

Medical History

Do you have any recent or past medical history of note?YesYesNoNoDo you have any allergies?YesYesNoNoHave you had a serious reaction to a vaccine given to you before?YesYesNoNoDoes having an injection make you feel faint?YesYesNoNoDo you or any direct family member(s) have epilepsy?YesYesNoNoDo you have any history of mental illness?YesYesNoNoHave you recently undergone radiotherapy, chemotherapy or steroid treatment?YesYesNoNoHave you taken out any travel insurance and if you have a medical condition, informed the insurance company about this?YesYesNoNoSend

Sent Message

About Us

Our vaccination and travel health clinics in Calgary, Edmonton, Ottawa, Toronto & Vancouver will ensure that you are up-to-date on all the travel immunizations recommended by healthcare professionals. Canadian Travel Clinics will ensure you are protected by all the recommended shots before you leave the country.

Book

CALL OUR APPOINTMENTS BOOKING LINE +1 888 672 0005

Mailing

Corporate Office:

Canadian Travel Clinics
Suite # 2010 - First Alberta Place
777 - 8 Avenue SW
Calgary, AB
T2P 3R5

+1 888 672 0005

Important Pages

About Us

Travel Clinic Calgary

Travel Clinics Toronto

Travel Clinics Vancouver

Travel Clinics Winnipeg

Travel Clinics Edmonton