Travel QuestionnaireSubmit your details using the form below, and one of our team members will be in touch to confirm your booking.Full name(Required)DOB(Required) DD slash MM slash YYYY Gender(Required) Female MaleNZ Address(Required) Street Address City ZIP / Postal Code Cell phone number(Required)Email(Required) Do you have any significant medical conditions?(Required) Yes NoPlease specifyDo you have any medical problems (including disorders of your thymus, thymoma or myasthenia gravis) that cause immunodeficiency?(Required) Yes NoPlease specifyHave you ever had a Deep Vein Thrombosis or Pulmonary Embolus?(Required) Yes NoPlease provide detailsHave you had major surgery in the last 6 months?(Required) Yes NoPlease provide detailsAre you pregnant, actively trying to be pregnant, or breast feeding?(Required) Yes NoDo you take any medications?(Required) Yes NoPlease list your regular medicationsIn the last 12 months have you taken any medications that cause you to be immunocompromised (including steroids, chemotherapy, or radiation)?(Required) Yes NoPlease specifyHave you travelled to less developed countries in the past?(Required) Yes NoPlease list countriesHave you had any troubles when previously travelling overseas?(Required) Yes NoPlease specifyTrip InformationDeparture date(Required) DD slash MM slash YYYY Return date(Required) DD slash MM slash YYYY Itinerary (including countries/cities/towns)(Required)Will you be visiting friends and/or relatives who live in the countries you are visiting?(Required)Will you be going to rural areas?(Required)Will you be hiking/biking to altitude or scuba diving?(Required)Vaccinations: If you have documentation of previous childhood and/or travel vaccines please bring these to your appointment.
