TRAVEL VACCINATION BOOKING FORM

Please fill out the form below to book your travel vaccinations

or phone us at: 07 839 7761

Who are you filling this form out for? (Please fill in a form for each individual)

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Full Name

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Date of Birth

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Gender

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New Zealand Address

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City

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Post Code

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Cell Phone Number

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Email

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Where are you traveling to? (Please list all destinations)

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How long are you traveling for?

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Leaving Date

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Return Date

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List all planned activities during travel

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Detail the purpose of the trip. (eg. visiting friends and relatives, work, holiday)

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What previous vaccinations have you had?

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Types of accommodation are you staying in?

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Do you have any significant medical conditions?

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Do you have any medical conditions that cause immunodeficiency?

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Have you had any surgery in the last 6 months?

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Any bleeding or clotting disorders?

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Are you pregnant, breastfeeding or planning pregnancy?

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Have you had a reaction to any previous vaccination before?

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Address

If you have any more questions see our FAQs

FAQs

Worldwise Travellers Health Hub – Hamilton Opening Hours

Mon to Thurs – 9am to 5pm
Friday – 9am to 4pm
Weekends – Closed

Where to find us

Inside Anglesea Pharmacy
Gate 1 or 2
Anglesea Pharmacy
Thackeray Street
HAMILTON

Phone: 07 839 7761
Email: hamilton@worldwise.co.nz

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