Yellow Fever Vaccine Form Yellow Fever Vaccine Form Patient InformationTravel InformationHealth History Book an appointmentMedication Information and Consent Welcome to our Yellow Fever 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 IslandsPreviousNextDo you have any allergies, particularly to eggs or chicken protein? Yes NoPlease expand on the allergy and type of reaction Do you take any regular medication? Yes NoPlease detail what medication you takeHave you previously had the yellow fever vaccine? Yes NoPlease describe why you need a booster dose Have any of your family members ever reacted to a previous yellow fever vaccine? Yes NoPlease detail the type of reaction Are you currently pregnant, breastfeeding, or trying to get pregnant? Pregnant Trying to get pregnant Breastfeeding None of the aboveDo you have any illness that might affect your immune system? Yes NoPlease detail the conditionsAre you taking any medicines (now or within the last year) that affect your immune system? Yes NoPlease detail the medication and when you took them Do you have cancer, or have you had cancer in the past Currently diagnosed with cancer Previously been diagnosed with cancer No current or previous cancer diagnosis Are you living with HIV? Yes NoAre you having chemotherapy or radiotherapy (now or within the last year)? Yes No10. Have you had an operation to remove your thymus gland (thymectomy) for any reason including during cardiac surgery? Yes NoPreviousNextSelect Appointment Date & TimePreviousNextVaccine Information and Consent Please read the following information carefully: The Yellow fever vaccine is recommended to protect against Yellow Fever, A serious infection caused by mosquitoes in certain areas of Africa as well as south and central America. The vaccine needs to be given at least 10 days before travel, and its protection lasts a lifetime. Common Side effects: mild fever, pain at the injection site, headache Serious Side effects: severe allergic reactions are rare but can occur I have read the information about the Yellow Fever vaccine. I understand the benefits and risks of the Yellow Fever 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
