Travel Advice Form

Balance Street

Travel Advice Form

Name
Date of birth
Address


Email address
Contact phone no.
Please select your Doctor

Are you planning any safaris, jungle exploring or travel in difficult terrain?

Yes

No

Will you be staying... in hotels camping with friends/family or other

Are you allergic to anything?	Yes	No	Please give details
Are you pregnant?	Yes	No
Are you breast feeding?	Yes	No
Are you trying to conceive?	Yes	No
Are you currently taking medication?	Yes	No	Please give details