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  Travel Clinic Information Form
Travel Clinic Information Form    
         
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      Travel Clinic Information Form


Please fill in the items below and click "Submit"
All Boxes must be filled in.

 
  Details of Travel Form Contact
  First Name
  Last Name
  Title
  Date of Birth  dd/mm/yyyy
  Post Code
  Email Address
  Phone Number
     
  Please List Persons Traveling
 
Example of text for above
1.Peter Smith Age 46
2. Alice Smith Age 38
Max input 20 lines. Please type "none" in the input box if you have no details.
 
Please Enter the "Dates", "Cities or Areas" and "Countries" for your Travel Plans
 
Example of text for above
1. 20/01/08 London UK
2. 21/01/08 New York USA
3. 25/01/08 Calcutta India
4. 30/02/08 London UK
Max input 20 lines. Please type "none" in the input box if you have no details.
 
Please Enter any Extra Information


Example of text for above
1. Peter Smith takes heart medication
2. We will be trekking to Nepal for 2 weeks.
3. Backpacking and staying in Hostels.
Max input 20 lines. Please type "none" in the input box if you have no details.

Important
Risks vary not only with the location you visit, but also with the activities that you undertake.

A week on a clean beach based in a good hotel is not the same risk as traveling through the countryside and staying in hostels.

Be sure to explain the "Type of Traveling" that you will be doing to help us offer you the best advice.
   

 
 
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