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Birthday
  
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Purpose of trip
Where will you be staying?
Possible activities
IMMUNIZATION HISTORY
XVaccineX
I declare that all the information provided on this form is accurate to the best of my knowledge and I understand that any fa lse information could be detrimental to my health
Note: Most vaccines are generally well tolerated; however, you may experience some soreness, redness and swelling at the inj ection site. Other adverse reactions may include headaches, fever, fatigue, and muscle pa in. As with any vaccine, an allergic reaction or anaphylactic response could occur.
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Purpose 1
Purpose 2
Purpose 3
Purpose 4
Purpose 5
Purpose 6
Purpose 7
Purpose 8
Staying 1
Staying 2
Staying 3
Staying 4
Staying 5
Staying 6
Staying 7
Cholera (Dukoral)
Hep A (Hepatitis A)
Hepatitis A & B combo
Hepatitis A & Typhoid combo
Hep B (Hepatitis B)
HPV (Gardasil/Cervarix)
Influenza
JE (Japanese Encephalitis)
Mantoux Test (TB Skin Test)
Meningitis
MMR (Measles Mumps Rubella)
Pneumococcal

Polio (IPV)
Rabies
Td (Diphtheria /Tetanus)
Tdp (Diphtheria/ Tetanus/ Polio)
Tda|p (Adacel)
Tick Borne Encephalitis
Typhoid Fever
YF (Yellow Fever)
ZOS (Zoster) (Shingles)
Other
Other
Would you like to book your appointment in Kingston or Belleville?*