Travel medication

Required fields are labelled

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Address:

Medication Required

You can attach a copy of your Right Hand Side at the end of this form.

Please state which medication you require:

Dates of Travel

Start date of travel:

Please use this date format: DD/MM/YYYY

End date of travel:

Please use this date format: DD/MM/YYYY

Time of Departure

Please state the time of your departure:

Letter for Travelling

It is the patients’ responsibility to check if a letter for travelling is needed.

Do you require a letter for travelling?

Yes

Confirmation

Confirmation Required

I have read and understand the Holiday Prescription Request Policy that is located on this page

Patient Signature: Required

Date:

Please attach a copy of your Right Hand Side:

Do not upload sensitive photographs of genitalia, bottoms (anus), breasts or minors without asking a healthcare professional first. Your uploads may be stored on your health record.

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Medication Required

Dates of Travel

Time of Departure

Letter for Travelling

Confirmation