Please note that you do now need to be registered with St Wulfstan as an NHS patient to benefit from this service.
Please complete and submit the form at least 3 months before your intended dates of travel. If you prefer to download a hard copy to complete and hand in to reception, you can print it off here.
In a few days, please make an appointment to see the nurse to go through the details.
Past Medical History
Vaccination History - Have you had any of the following? Please give dates.
For Health Professional Use Only:
For Reception Use Only
Date Received ....../......./.......
Received by ..........................
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.