Cholera Vaccine Form Cholera Vaccine Form Patient InformationTravel InformationHealth History Book an appointmentMedication Information and Consent Welcome to our Cholera Vaccine FormPlease fill out this form so your clinician can recommend the best treatment plan for you.First NameLast NameEmailPhone/MobileAddressAddress Line 1CityPostcodeCountryUnited KingdomUnited Kingdom (UK)Date of birth Sex at birth Male FemaleEmergency Contact NameEmergency Contact Phone NumberPreviousNextDestination(s) of TravelStart typing to searchAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsDeparture DateReturn DatePurpose of travel Business Leisure Visiting family OtherPlease ElaboratePreviousNextDo you have any allergies to medications, foods, or other substances? Yes NoPlease listHave you ever had a serious reaction to a vaccine in the past? Yes NoPlease describeDo you have any chronic health conditions (e.g., asthma, diabetes, heart disease)? Yes NoPlease listAre you currently pregnant, breastfeeding, or trying to get pregnant? Pregnant Trying to get pregnant Breastfeeding None of the aboveDo you have a weakened immune system (e.g., HIV/AIDS, cancer, medications that affect the immune system)? Yes NoPlease describeHave you received any other vaccines in the past 4 weeks? Yes Nowhich one(s)?Have you ever received the Cholera vaccine before? Yes Nowhen?Do you have a history of seizures or epilepsy? Yes NoDo you have a bleeding disorder or are you taking blood-thinning medications? Yes NoPreviousNextSelect Appointment Date & TimePreviousNextVaccine Information and Consent Please read the following information carefully: The Cholera vaccine is recommended to protect against cholera, an acute diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae. The vaccine is typically administered orally. Common side effects: Mild gastrointestinal symptoms, headache, and fatigue. Serious side effects: Severe allergic reactions are rare but can occur. I have read the information about the Cholera vaccine. I understand the benefits and risks of the Cholera vaccine and request that the vaccine be given to me or to the person named above for whom I am authorised to make this request. Previous Submit Form
